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THE  OATH  OF  HIPPOCRATES 


1 SWEAR  BY  APOLLO  THE  PHYSI- 
CIAN AND  AESCULAPIUS  AND 
HEALTH  AND  ALL-HEAL  AND 
ALL  THE  CODS  AND  GODDESSES 
THAT  ACCORDING  TO  MY  ABIL- 
ITY AND  JUDGMENT  I WILL 
KEEP  THIS  OATH  AND  THIS 
STIPULATION  A A A A 

4 O RECKON  HIM  WHO 
TAUCHT  ME  THIS  ART 
EQUALLY  DEAR  TO 
ME  AS  MY  PARENTS 
TO  SHARE  MY  SUB- 
STANCE WITH  HIM  AND  RELIEVE 
HIS  NECESSITIES  IF  REQUIRED 
TO  LOOK  UPON  HIS  OFFSPRING 
IN  THE  SAME  FOOTINC  AS  MY 
OWN  BROTHERS  AND  TO  TEACH 
THEM  THIS  ART  IF  THEY  SHALL 
WISH  TO  LEARN  IT -WITHOUT 
FEE  OR  STIPULATION  AND 
THAT  BY  PRECEPT  LECTURE 
AND  EVERY  OTHER  MODE  OF 
INSTRUCTION  I WILL  IMPART 
A KNOWLEDGE  OF  THE  ART  TO 
MY  OWN  SONS  AND  THOSE  OF 
MY  TEACHERS  AND  TO  DISCI- 
PLES BOUND  BY  A STIPULATION 
AND  OATH  ACCORDING  TO 
THE  LAW  OF  MEDICINE  • BUT  TO 
NONE  OTHERS  < I WILL  FOL- 
LOW THAT  SYSTEM  OF  REGIMEN 
WHICH  ACCORDING  TO  MY 
ABILITY  AND  JUDGMENT  I CON- 
S1DER  FOR  THE  BENEFIT  OF  MY 
PATIENTS -AND  ABSTAIN  FROM 
WHATEVER  IS  DELETERIOUS 


CIVE  NO  DEADLY  MEDICINE 
TO  ANYONE  IF  ASKED  • NOR  SUG- 
CESTANY  SUCH  COUNSEL- AND 
IN  LIKE  MANNER  I WILL  NOT 
GIVE  TO  A WOMAN  A PESSARY 
TO  PRODUCE  ABORTION dfwiTH 
PURITY  AND  WITH  HOLINESS  I 
WILL  PASS  MY  LIFE  AND  PRAC- 
TICE MY  ART<p  WILL  NOT  CAS- 
TRATE  ANYONE  NOT  EVEN 
THOSE  LABORINC  UNDER  THE 
STONE  AND  WILL  SHUN  MEN 
WHO  ARE  PRACTITIONERS  OF 
THIS  WORK<f  INTO  WHATEVER 
HOUSES  1 ENTER  I WILL  CO  INTO 
THEM  FOR  THE  BENEFIT  OF  THE 
SICK  • AND  WILL  ABSTAIN  FROM 
EVERY  VOLUNTARY  ACT  OF  MIS- 
CHIEF  AND  CORRUPTION  AND 
FURTHER  • FROM  THE  SEDUC- 
TION OF  FEMALES  OR  MALES  OF 
FREEMEN  AND  SLAVES  ^WHAT- 
EVER IN  CONNECTION  WITH  MY 
PROFESSIONAL  PRACTICE  OR 
NOT  IN  CONNECTION  WITH  IT 
I SEE  OR  HEAR  IN  THE  LIFE  OF 
MEN  WHICH  OUCHT  NOT  TO 
BE  SPOKEN  OF  ABROAD  1 WILL 
NOT  DIVULGE  AS  RECKONING 
THAT  ALL  SUCH  SHOULD  BE 
KEPT  SECRET  WHILE  I CON- 
TINUE TO  KEEP  THIS  OATH  UN- 
VIOLATED MAY  IT  BE  GRANTED 
TO  ME  TO  ENJOY  LIFE  AND 
THE  PRACTICE  OF  THE  ART  RE- 
SPECTED BY  ALL  MEN  IN  ALL 
TIMES  BUT  SHOULD  I TRESPASS 
AND  VIOLATE  THIS  OATH  - MAY 


; 


Digitized  by  the  Internet  Archive 
in  2016 


https://archive.org/details/observationsonsu01burn 


OBSERVATIONS 


ON  THE 

SURGICAL  ANATOMY 

OF  THE 

HEAD  AND  NECK, 

ILLUSTRATED  BY 

(Cases  antr  iEuflraWufls* 


BY  ALLAN  BURNS, 

Member  of  the  Royal  College  of  Surgeons,  London;  and  Lecturer  on 
Anatomy  and  Surgery,  Glasgow. 


FIRST  AMERICAN  EDITION. 

WITH  A LIFE  OF  THE  AUTHOR; 

AND  ADDITIONAL 

CASES  AND  OBSERVATIONS. 


BY  GRANVILLE  SHARP  PATTISON,  SURGEON, 

Professor  of  Surgery  in  the  University  of  Maryland,  He.  He. 


Baltimore: 

PUBLISHED  BY  F.  LUCAS,  JB.,  E.  J.  COALE,  AND  CUSHING  & JEWETT; 
and 

H.  CARET  & I.  LE  \,  PHILADELPHIA, 

John  D.  Toy,  printer. 

1823. 


1 


%> 


v._ 


3^'<y\ 


DISTRICT  OF  MARYLAND,  TO  WIT: 

BE  IT  REMEMBERED  Thai  on  this  seventh  day  of  August,  in  the  forty-eighth  year  of  the  incr. c: 
of  the  United  Slates  of  Ameiic,.  Granville  Sharp  Pattisun,  of  the  said  District  hath  deposited  in  th  j the 

title  of  3 book,  the  right  whereof  he  claims  as  proprietor,  in  the  words  following,  to  wit. 

“Observations  on  the  Surgical  Anatomy  of  the  Head  and  Neck,  :!:u$tra'fd  by  Cases  and  Engravings.  B Allan  Bums. 
Member  of  the  Rova!  College  of  Surgeons,  London;  and  Lecturer  on  Anatomy  and  Surgery.  Glasgow  First  American 
Edition,  with  a Life  of  the  Author:  and  additional  Cases  and  Observations.  By  Granville  Sharp  Pattiso.i.  Surgeon, 
Professor  of  Surgery  in  the  University  of  Maryland,  &e,  &c  ” 

In  conformity  with  the  Act  of  the  Congress  of  the  United  States,  entitled,  ‘An  Act  lor  the  encouragement  of  l--nrng, 
by  securing  the  copies  of  ra-ps,  charts,  and  Kooks,  to  the  authors  and  proprietors  of  such  copies,  darog  the  rimes 
therein  mentioned;  *’  and  also  to  the  Act,  entitled,  “An  Act  Supplementary  to  the  Act,  entitled,  ‘An  Ac  io»  the 
encouragement  of  learning,  by  securing  the  copies  of  maps,  cruits  and  books,  to  the  authors  aid  pro  iruri  of 
such  copies,  during  the  times  therein  mentioned,’  and  extending  the  benefits  thereof  to  the  <rts  of  designing.  eogr-.\>.g 
and  etching,  historical  and  other  prints." 

PHILIP  MOORE, 

Clerk  of  the  District  ojldanlani- 


EDITOR’S  PREFACE 


TO  THE 

FIRST  AMERICAN  EDITION. 


To  affix  one’s  name  to  the  productions  of 
others,  as  the  editor  of  their  works,  has  ever 
appeared  to  me  a very  humble  office  for  a 
man  who  has  a respect  for  his  own  reputation. 
I am  aware  that  this  has  been  much  in  fashion 
in  this  country;  and,  that  even  men  of  distin- 
guished character  and  great  acquirements, 
have  condescended  to  become  the  mere  press 
correctors  for  their  Trans-atlantic  brethren.  I 
trust  the  day  will  never  arrive  when  we  shall 
cease  to  value  European  publications  of  merit; 
hut,  I sincerely  hope,  that  the  time  is  now  at 
hand,  when  men  of  talent  in  this  country, 
1 


11 


editor’s  preface. 


will  disdain  to  become  the  name-fathers  of 
works  for  which  they  have  only  performed 
the  slavish  duty  of  reading  the  proofs,  and 
correcting  the  typographical  errors.  As  I at 
present  appear  before  the  public  in  this  cha- 
racter; one,  which  under  other  circumstances 
I should  consider  a degradation,  I am  very 
anxious  that  the  objects  which  have  induced 
me  to  do  so,  should  be  fully  understood. 

My  late  very  dear  friend,  Allan  Burns,  pub- 
lished the  present  volume  as  the  commence- 
ment of  a series,  it  having  been  his  intention 
to  have  proceeded  upon  the  same  plan,  and 
described  all  the  other  parts  of  the  body,  so  as 
to  have  formed  a complete  system  of  Surgical 
Anatomy.  The  Surgical  Anatomy  of  the  Head 
and  Neck,  was  however,  all  of  the  work  which 
he  was  permitted  to  finish,  and  I am  not 
aware  that  he  has  left  a single  note  for  the 
completion  of  the  other  departments  of  the 
system. 

Honoured  by  Mr.  Burns  during  the  term  of 
my  professional  studies,  with  a friendship  and 


editor’s  preface.  iii 

affection  which  resembled  more  the  love  of  a 
brother  than  the  regard  of  a preceptor,  at 
his  death  I was  bequeathed,  as  a testimony  of 
his  esteem,  the  copy-rights  of  all  his  works. 
My  having  become  the  legal  possessor  of  these, 
is  not  however  the  cause  which  has  induced 
me  to  become  their  editor.  The  Surgical 
Anatomy  of  the  Head  and  Neck  having  been 
out  of  print,  I was  applied  to,  before  I left 
Europe,  for  permission  to  publish  a new  edi- 
tion, to  continue  myself  the  plan  which  Mr. 
Burns  had  commenced,  and  to  complete,  by  a 
series  of  new  volumes,  the  Surgical  Anatomy 
of  the  whole  Body.  My  removal  to  this  coun- 
try having  prevented  me  at  that  time  from 
fulfilling  this  engagement,  the  object  of  the 
present  publication  is  now  to  commence  it,  and 
I propose  to  publish  every  autumn  a new 
volume,  until  the  system  shall  be  completed. 
Feeling  persuaded  from  my  education,  that 
had  I attempted  to  write  myself  the  volume 
on  the  Head  and  Neck,  that  my  views  and 
descriptions  would  have  borne  so  close  a 


iv  editor’s  preface. 

resemblance  to  those  of  Mr.  Burns,  as  to  have 
subjected  me  to  the  charge  of  plagiarism,  I 
have  considered  it  best  that  his  work  should 
form  the  first  volume  of  the  series. 

In  republishing  the  Surgical  Anatomy  of 
the  Head  and  Neck,  I have  added  a life  of  the 
author,  and  an  Appendix.  In  the  former,  I 
have  given  a very  short  history  of  Mr.  Burns’ 
professional  labours,  other  circumstances  hav- 
ing been  merely  stated  so  far  as  they  have 
tended  to  connect  and  illustrate  their  origin, 
and  the  order  of  their  occurrence.  Knowing 
well  the  high  reputation  which  this  book  has 
obtained  in  Great  Britain,  I have  felt  so  appre- 
hensive, lest  it  should  be  suspected  that  by  its 
publication,  I was  desirous  to  obtain  a surrep- 
titious reputation,  that  even  in  the  Appendix  I 
have  endeavoured  to  avoid,  as  much  as  possi- 
ble, any  appearance  of  attempt  at  originality. 
Therefore,  in  stating  any  improvements,  I 
have  employed,  where  I had  the  power,  the 
language  of  their  authors.  I once  intended  to 
have  posted  up  all  that  had  been  done  in  the 


editor’s  preface. 


V 


branches  of  surgery  mentioned  in  this  work, 
from  its  publication  to  the  present  day,  but, 
I soon  discovered  that  to  do  so,  I should 
have  been  obliged  to  make  the  Appendix  as 
large  as  the  rest  of  the  book.  I have  there- 
fore confined  myself  to  the  relation  of  some 
remarkable  cases  which,  from  their  connex- 
ion with  the  anatomy  of  the  head  and  neck, 
tend  either  to  support  or  controvert  the  opin- 
ions of  Mr.  Burns.  In  the  future  volumes, 
the  subjects  of  aneurism,  tumours,  &c.  &c. 
will  necessarily  require  to  be  mentioned,  and  I 
shall  then  have  an  opportunity  of  laying  before 
my  readers,  a concise  statement  of  any  new 
views  or  modes  of  treatment  introduced  to 
public  notice,  since  the  date  of  the  publication 
of  the  first  edition  of  this  work. 


Baltimore , Oct.  10,  1823. 


A 


SHORT  ACCOUNT 

OF 

THE  LIFE  OF  THE  AUTHOR. 


Mr.  Allan  Burns  was  born  at  Glasgow,  on 
the  18th  of  September,  1781.  His  father,  the 
Rev.  John  Burns,  D.  D.  is  still  alive,  and  is 
one  of  the  oldest  and  most  respectable  members 
of  the  Established  Kirk  of  Scotland. 

The  period  of  Mr.  Burns’  life  prior  to  the  com- 
mencement of  his  medical  studies,  was  marked  by 
no  event  worthy  of  notice.  By  his  teachers  and 
friends  he  was  considered  a boy  of  good  talents; 
but  it  was  only  after  he  commenced  the  study  of 
medicine,  a pursuit  towards  which  his  mind  seemed, 
from  his  earliest  boyhood  to  have  a particular  bent, 
that  his  abilities  were  brought  into  full  action. 

At  the  early  age  of  fourteen  years,  Mr.  Burns  en- 
tered the  medical  classes,  and  by  his  diligence  and 


Vlll 


LIFE  OF  THE  AUTHOR. 


application,  he  was  enabled  two  years  afterwards 
to  take  upon  himself  the  sole  direction  of  the  dis- 
secting-rooms of  his  brother,  Mr.  John  Burns,  who, 
at  that  time  was  a lecturer  on  anatomy  and  surgery 
in  Glasgow.  From  the  excellent  opportunities  he 
here  enjoyed  for  cultivating  the  study  of  anatomy, 
and  from  the  enthusiasm  with  which  he  pursued 
anatomical  inquiries,  it  is  not  surprising  that  he 
soon  became  a very  good  practical  anatomist.  But 
his  mind  was  not  to  be  satisfied  with  mediocrity; 
he  was  anxious  to  be  superior,  not  equal  with  his 
cotemporaries.  Placing  before  himself,  as  models 
for  imitation,  the  men  who  had  been  the  most  dis- 
tinguished in  his  profession,  and  aware,  from  their 
histories,  that  they  had  only  obtained  honour  and 
eminence  by  unwearied  application,  his  exertion 
in  the  pursuit  of  professional  knowledge,  so  far 
from  relaxing,  increased  with  his  acquirements. 

In  fulfilling  the  duties  of  his  situation  as  his 
brother’s  demonstrator,  it  was  necessary  for  Mr. 
Burns  to  be  much  occupied  in  making  anatomical 
preparations.  The  preservation  of  preparations 
in  spirits  was  performed  before  his  time,  in  as 
elegant  a manner  as  possible  by  the  Hunters  and 
Monros.  Vascular  preparations  were,  however, 
by  no  means,  dexterously  executed;  to  the  preser- 


LIFE  OF  THE  AUTHOR. 


IX 


vation  of  these  he  therefore  particularly  directed 
his  attention; — he  changed  both  the  injections  and 
manner  of  injecting;  he  dissected  the  parts  more 
minutely  than  had  been  done  before  him,  and,  from 
his  attention  to  this  branch,  I can  state  without 
hesitation,  that  his  collection  of  vascular  prepara- 
tions were,  at  one  time,  superior  to  any  other  in 
the  world. 

Mr.  Burns’  time  was,  however,  at  this  period 
by  no  means  wholly  occupied  in  making  prepara- 
tions; he  visited  a number  of  his  brother’s  cases, 
and  noting  the  symptoms  of  the  different  diseases, 
he  endeavoured  to  explain  these  on  anatomical 
principles.  Where  the  patients  died,  he,  if  pos- 
sible, obtained  permission  to  inspect  the  body, 
and,  when  he  succeeded  in  this,  he  compared  the 
morbid  appearances  with  his  former  speculations, 
which,  if  correct,  became  fixed  on  his  mind;  if 
the  reverse,  he  endeavoured  to  account  for  the 
symptoms  from  the  disorganization  which  had 
been  produced.  Conducting  these  examinations 
with  a minuteness  and  attention  which  is  very 
rarely  bestowed  upon  them,  he  was  much  struck 
with  the  frequency  of  mal -formation  in  the  me- 
chanism, or  morbid  change  in  the  structure  of  the 
heart.  In  a number  of  cases,  where  the  symptoms 


X 


LIFE  OF  THE  AUTHOR. 


manifested  during  the  progress  of  the  disease,  had 
led  the  physician  to  form  very  incorrect  views  as 
to  its  seat,  his  dissections  proved  the  heart  to  have 
been  the  viscus  affected.  Cardiac  affections  appear- 
ed to  him  to  be  a subject  so  important,  yet  so  little 
understood,  that  he  devoted  himself  with  great 
attention  to  their  investigation  He  watched,  and 
endeavoured  to  distinguish  and  characterize  the 
Protean  symptoms  which  they  presented  during 
life;  and  after  death  the  morbid  changes  were  at- 
tentively noted.  From  Mr.  Burns’  labours  in 
this  hitherto  much  neglected  class  of  diseases,  he 
had  soon  in  his  Case  Book  a vast  fund  of  original 
information  on  these  interesting,  but  ill  understood 
affections.  At  this  period,  however,  he  had  no 
intention  of  publishing  on  that  subject,  his  atten- 
tion being  much  occupied  in  collecting  materials 
for  a work  which  he  proposed  to  give  to  the  pub- 
lic on  the  subject  of  Hernia. 

Mr.  Burns,  during  the  summer  of  1802,  whilst 
dissecting  the  part  concerned  in  the  operation  for 
crural  hernia,  discovered  a process  of  the  fascia 
lata , which  had  never  before  been  described  by 
anatomists,  and  in  attending  to  the  pathology  of 
the  disease,  in  relation  to  this  process,  which  he 
named  falciform,  he  found  that  it  had  a very  great 


LIFE  OF  THE  AUTHOR.  xi 

effect  upon  the  strangulation  in  certain  cases  of 
incarceration.  It  was  this  discovery  which  led 
him  to  pay  particular  attention  to  hernia,  and  to 
prepare  for  the  press  the  work  on  that  subject, 
which  has  been  already  alluded  to.  The  pub- 
lication of  Mr.  Cooper’s  splendid  work  on  hernia, 
prevented  him  from  laying  his  thoughts  on  this 
subject  before  the  public  in  the  form  of  a volume. 
He,  however,  in  the  year  1806,  published  a very 
perspicuous  paper  “On  the  Anatomy  of  the  parts 
concerned  in  Femoral  Rupture,”  in  the  Edin- 
burgh Medical  and  Surgical  Journal. 

In  the  year  1804,  Mr.  Burns,  having  deter- 
mined to  enter  the  medical  service  of  the  army, 
went  to  London,  for  the  purpose  of  obtaining  a 
commission;  but,  previous  to  his  making  an  appli- 
cation for  one,  he  received  a letter,  offering  him  a 
situation  in  St.  Petersburg,  of  which  he  accept- 
ed, and  accordingly  left  London  for  the  purpose 
of  repairing  to  Russia. 

The  empress  Catharine,  acting  in  the  name  of 
her  son  Alexander,  having  established,  in  the 
metropolis  of  her  country,  an  hospital  on  the 
English  plan,  was  desirous  of  procuring  for  its 
director  an  able  British  surgeon.  For  this  office 
Mr.  Burns  was  named  to  her  majesty,  by  his  ex- 


xii  LIFE  OF  THE  AUTHOR. 

cellency  Dr.  Creighton,  as  a gentleman  in  every 
way  qualified;  the  appointment  was  according- 
ly immediately  offered  for  his  acceptance — and, 
by  a further  indulgence  of  the  empress,  he  was 
allowed  to  remain  six  months  in  the  country,  be- 
fore he  was  required  to  make  up  his  mind  on  the 
subject  of  the  appointment.  Passionately  at- 
tached to  the  customs  and  institutions  of  his  own 
country,  after  the  term  of  trial,  he  could  not  be 
induced,  valuable  as  the  appointment  was,  to 
accept  of  it;  and  the  empress,  finding  that  his 
determination  to  return  to  Scotland  could  not  be 
changed,  presented  to  him,  in  testimony  of  her 
admiration  of  his  character,  a very  valuable  dia- 
mond ring. 

In  the  month  of  January,  1805,  Mr.  Burns  left 
St.  Petersburg,  and  having  travelled  through 
Sweden,  he  arrived  in  London  the  following 
April. 

Mr.  John  Burns  having  discontinued  his  lec- 
tures on  anatomy  and  surgery,  the  idea  of  re- 
turning to  Glasgow  and  delivering  lectures  on 
these  subjects,  was  first  suggested  to  his  brother’s 
mind  whilst  residing  in  Russia.  This  plan  was 
so  congenial  to  his  inclination,  that  on  his  return 
home,  he  at  once  began  to  occupy  himself  in  pre- 


LIFE  OF  THE  AUTHOR. 


XIII 


paring  a course  of  lectures;  and  the  following 
winter  he  commenced  his  eareer  as  a Public 
Teacher. 

In  the  autumn  of  1808,  Mr.  Burns  prepared 
his  work  on  the  Diseases  of  the  Heart  for  publi- 
cation, and  printed  it  early  the  following  spring. 

During  the  spring  of  1810,  Mr.  Burns  was 
attacked  with  dyspeptic  symptoms.  With  the 
view  of  removing  these,  he  was  induced,  at  the 
termination  of  his  lectures,  to  travel  to  the  island 
of  Arran,  where  he  remained  a month.  From 
this  journey,  his  health  was  so  completely  re-esta- 
blished, that  he  was  enabled,  on  his  return  to 
Glasgow,  to  enter  again,  with  his  wonted  ardour 
on  his  professional  pursuits.  The  restoration  to 
health  was,  however,  of  short  duration;  his  close 
application  to  study,  and  constant  attendance 
at  the  dissecting  rooms,  having  been  the  causes 
which  originally  gave  the  disposition  to  the  dis- 
ease, soon  reproduced  it.  In  a few  months  he 
was  in  a much  worse  state  of  health  than  he  had 
been  previous  to  his  visit  to  Arran;  but,  so  much 
interested  and  occupied  was  he  in  preparing  ma- 
terials for  the  publication  of  his  work  on  the  Sur- 
gical Anatomy  of  the  Head  and  Neck,  that  no 


XIV 


LIFE  OF  THE  AUTHOR. 


persuasions  could  prevail  upon  him  to  relax  in 
his  application  and  visit  the  country. 

His  complaints  increased  so  rapidly  during  the 
spring  of  1811,  that  he  was  with  great  difficulty 
enabled  to  finish  his  lectures.  So  soon  as  he 
had  concluded  them,  he  left  Glasgow  for  the 
island  of  Cambray,  where  he  remained  for  a 
month.  His  health  having  been  considerably 
benefited  by  this  short  visit,  the  hopes  of  his 
friends  became  elevated,  and  he  was  induced,  by 
their  solicitations,  to  remain  for  only  a very 
short  time  in  Glasgow.  To  gratify  them,  he 
determined  to  make  a voyage  to  the  Hebrides. 

From  the  sea  air,  exercise,  and  change  of  scene, 
Mr.  Burns  appeared  to  derive  much  benefit,  but, 
towards  the  close  of  the  voyage,  he  had  a most 
severe  attack  of  cholera  morbus,  a disease  to 
which  he  had  not  before  been  subject,  and  which, 
in  a great  measure,  destroyed  all  the  advantages 
which  he  had  before  received  from  his  excursion. 
Indeed,  he  returned  to  Glasgow  in  the  month  of 
September,  in  a more  debilitated  state  of  health 
than  when  he  left  it,  on  his  departure  for  the  He- 
brides. Yet,  although  his  health  was  in  a most 
wretched  state,  his  mind  was  still  in  the  meri- 
dian of  its  vigour;  his  ardour  in  the  improve- 


LIFE  OF  THE  AtJTHOR. 


XV 


ment  of  his  profession  continued  unabated,  and 
his  zeal  was  such,  that,  immediately  after  his  re- 
turn to  Glasgow,  he  laboured  more  diligently  than 
ever,  in  finishing  his  work  on  the  Surgical  Ana- 
tomy of  the  Head  and  Neck,  which  he  published 
a few  months  afterwards. 

This  second  work  of  Mr.  Burns,  must  remain 
a most  valuable  standard  work  as  long  as  surgery 
continues  to  be  cultivated  as  a science.  It  con- 
tains no  hypothesis  nor  theories,  but  consists  en- 
tirely of  pathological  inferences,  drawn  from  the 
most  acute  and  accurate  observations  on  the  ana- 
tomical structure  of  the  parts. 

Ever  after  the  period  when  Mr.  Burns  had  the 
attack  of  cholera  morbus,  he  continued  so  subject 
to  this  complaint,  that  if  he  happened  to  eat  fruit, 
or  was  exposed  to  the  slightest  change  of  tem- 
perature, he  was  seized  with  a paroxysm  of  this 
most  painful  disease.  From  the  frequent  recur- 
rence of  the  cholera,  and  the  continued  uneasi- 
ness produced  by  the  dyspepsia,  his  strength  and 
spirits  became  so  much  exhausted  during  the  win- 
ter session,  that  he  was  under  the  necessity  of 
concluding  his  lectures  a month  before  the  usual 
period  for  their  termination;  and,  immediately  on 
their  conclusion,  he  left  the  city  for  the  island  of 


XVI 


LIFE  OF  THE  AUTHOR. 


Bute,  where  he  remained  until  the  month  of 
September. 

Having  occasion  to  visit  London  that  summer, 
I was  separated  from  Mr.  Burns  for  the  first  time 
since  the  commencement  of  our  acquaintance. 
When  I visited  Bute,  after  an  absence  of  three 
months,  I was.  delighted  to  observe  the  great 
improvement  which  air  and  exercise  had  pro- 
duced in  his  appearance.  He  seemed  restored 
to  perfect  health;  but,  unfortunately,  all  he  had 
gained  during  the  summer,  was  lost  by  a violent 
attack  of  cholera,  which  he  had  the  day  after  his 
return  to  Glasgow.  As  this  paroxysm  may  be 
considered  as  the  primary  cause  of  the  disease 
which  produced  Mr.  Burns’  death,  a particular 
account  of  it  may  be  interesting. 

The  evening  before  the  attack,  Mr.  Burns  and 
myself  spent  together  in  the  dissecting-room.  We 
were  busily  employed  in  dissecting  and  preparing 
a piece  of  morbid  structure,  and  were  under  the  ne- 
cessity of  using,  in  its  preservation,  a considerable 
quantity  of  corrosive  sublimate.  Whether  a small 
quantity  of  this  mineral  had  or  had  not  been  inhaled 
by  Mr.  Burns,  it  is  impossible  to  decide.  The  vio- 
lence of  the  attack  of  cholera  which  followed  seemed 
to  indicate  some  such  cause  for  its  production.  On 


LIFE  OF  THE  AUTHOR. 


xvii 


taking  leave  of  me,  after  our  departure  from  the 
dissecting-rooms,  he  appeared  to  have  a melan- 
choly foreboding  of  what  was  to  happen,  and  un- 
fortunately it  was  too  just.  At  two  o’clock  in  the 
morning  I was  called  up  by  a messenger,  request- 
ing me  immediately  to  visit  him.  Upon  my  arri- 
val at  his  house,  I found  him  in  a state  of  the  most 
indescribable  agony.  The  violence  of  the  disease 
was  such,  that  not  only  the  muscles  of  the  abdo- 
men, but  likewise  those  of  the  extremities,  were 
under  the  influence  of  severe  spasms.  Laudanum 
and  other  medicines  were  administered  in  very 
large  doses,  but  he  remained  in  this  state  of  suf- 
fering until  eight  o’clock,  a.  m.  when  the  symptoms 
began  gradually  to  abate.  For  some  days  after- 
wards his  life  was  despaired  of,  but  by  care  and 
attention,  he  was  enabled  in  a fortnight  to  leave 
his  bed. 

From  an  anxiety  to  gain  sufficient  strength  to 
enable  him  to  fulfil  his  laborious  winter  vocations, 
so  soon  as  Mr.  Burns  was  able  to  travel,  he  re- 
turned to  the  island  of  Bute,  where  he  remained 
for  three  weeks.  From  this  visit  his  general 
health  was  considerably  benefitted,  but,  he  suffered 
constantly  during  his  absence,  from  a severe  pain 
in  the  right  iliac  region,  the  muscles  in  this  situa- 
3 


XV111 


LIFE  OF  THE  AUTHOR. 


tion  having  been  particularly  affected  with  spasms 
during  the  late  attack  of  cholera.  This  pain  con- 
tinued,  although  with  less  severity,  after  his  re- 
turn home;  he  described  it  as  perfectly  fixed,  and 
so  local  that  he  could  cover  it  with  the  point  of 
his  finger. 

In  this  miserable  state  of  health,  Mr.  Burns 
commenced  his  last  course  of  lectures,  but  was  only 
permitted  to  continue  them  for  a very  short  time. 
During  the  second  week  of  the  session,  an  abscess 
burst  into  the  rectum  and  discharged  about  two 
ounces  of  pus.  The  discharge  became  every  day 
more  and  more  profuse;  the  constitution  began  to 
suffer,  and  in  a week  Mr.  Burns  found  it  neces- 
sary to  confine  himself  to  his  bed,  which  he  never 
afterwards  left  for  more  than  a few  hours. 

It  is  unnecessary  to  detail  the  progress  of  the 
disease;  like  other  internal  abscesses,  it  under- 
mined the  powers  of  the  system,  and  speedily  pro- 
duced hectic  fever,  which  terminating  in  colliqua- 
tive diarrhoea,  closed  the  scene  on  the  twenty- 
second  of  June,  1813. 

Twenty-four  hours  after  death  the  body  was 
examined  by  Dr.  Brown,  Mr.  Russel,  and  some 
other  professional  gentlemen. 


LIFE  OF  THE  AUTHOR. 


XIX 


From  the  last  attack  of  cholera  morbus  until 
the  period  of  his  death,  Mr.  Burns  having  com- 
plained of  a continued  and  local  pain  in  the  situa- 
tion of  the  right  iliac  region,  this  part  of  the  ab- 
domen naturally  attracted  particular  attention. 
The  most  superficial  examination  at  once  dis- 
covered that  morbid  changes  had  taken  place 
in  it.  The  caput  colli,  instead  of  being  simply 
bound  down  to  the  surface  of  the  iliacus  inter- 
ims, by  the  inflexion  of  the  peritoneum,  was 
firmly  united  by  a deposition  of  coagulable  lymph 
to  that  membrane,  where  covering  the  inferior 
portion  of  the  transversalis  abdominis,  the  adhe- 
sion between  this  part  of  the  muscle  and  the  caput 
colli,  was  so  perfect,  that  the  one  could  not  be 
separated  from  the  other.  On  dissecting  and 
separating  the  transversalis  from  the  obliquus  in- 
ternus,  an  abscess  was  discovered  situated  be- 
tween them,  just  above  the  point  where  they  are 
attached  to  Poupart’s  ligaments.  From  this  ab- 
scess, two  sinus  openings  passed  off;  on  trac- 
ing them,  the  one  was  found  to  terminate  in  the 
caput  colli,  and  the  other  was  followed  completely 
under  that  portion  of  the  intestine  towards  the 
promontory  of  the  sacrum;  from  thence  taking  as 
its  guide  the  rectum,  it  ran  down  about  four 


XX 


LIFE  OF  THE  AUTHOR. 


inches,  and  then  entered  the  gut.  The  other  vis- 
cera of  the  abdomen,  as  well  as  those  of  the  chest, 
were  healthy.  This  examination  satisfactorily 
explained  all  the  circumstances  of  the  case*  The 
spasm,  which  wa1*  particularly  severe,  during  the 
last  attack  of  cholera,  in  the  situation  of  the  right 
iliac  region,  had  probably  produced  a tearing  of 
the  fibres  of  the  transversalis  muscle.  This  was 
followed  by  inflammation,  which  ended  in  sup- 
puration An  abscess  being  thus  formed  between 
the  obliquus  internus  and  transversalis  abdomi'is, 
ulceration  of  that  portion  of  the  latter  muscle 
which  formed  the  abdominal  wall  of  the  sac  na- 
turally occurred.  The  peritoneum  covering 
it  became  inflamed,  and,  as  the  inflammation  of 
that  membrane  is  necessarily  followed  by  the  effu- 
sion of  coagulable  lymph,  an  adhesion  was  esta- 
blished between  it  and  the  caput  colli.  The  ab- 
scess being  thus  prevented  from  discharging  its 
contents  into  the  belly,  sinuses  passed  off  from  it, 
one  of  which  opened  into  the  caput  colli,  and  the 
other  into  the  rectum. 

Before  concluding  this  biographical  sketch  of 
Mr.  Burns’  life,  it  is  proper  to  make  a few  obser- 
vations on  his  character,  viewed  as  an  Author, 
a Public  Teacher,  and  a Man. 


LIFE  OF  THE  AUTHOR. 


XXI 


Mr.  Burns  has  left  behind  him  four  works. 
Two  of  which  were  Essays  published  in  the 
Medical  and  Surgical  Journal  of  Edinburgh.  The 
one  on  the  anatomy  of  the  parts  concerned  in  the 
operation  for  Crural  Hernia,  and  the  other  on  the 
operation  of  Lithotomy.  His  first  elaborate  work  is 
an  octavo  volume  of  three  hundred  and  twenty- 
two  pages,  entitled.  “ Observations  on  some  of 
the  most  frequent  and  important  diseases  of  the 
heart;  on  aneurism  of  the  thoracic  aorta;  on 
preternatural  pulsation  in  the  epigastric  re- 
gion: and  on  the  unusual  origin  and  distribu- 
tion of  some  of  the  large  arteries  of  the  human 
body.  Illustrated  by  cases.”  The  other  is  the 
work  now  offered  to  the  profession  in  America. 
Of  the  Essays  which  he  published  in  the  Edin- 
burgh Journal,  I shall  only  observe,  that  they  dis- 
play great  anatomical  knowledge,  and  that  per- 
spicuity of  description  for  which  Mr.  Burns  was 
eminently  distinguished,  both  as  a writer  and  a 
teacher. 

When  it  is  recollected,  that  although  “before 
the  publication  of  Mr.  Burns’  book,  many  detach- 
ed works  had  been  published  on  particular  affec- 
tions of  the  heart,  that,  still  no  treatise  had  ap- 
peared presenting  a connected  view  of  the  causes 


xxii 


LIFE  OF  THE  AUTHOR. 


and  consequences  of  the  various  diseases  to  which 
that  most  important  organ  is  liable, ” and  when 
it  is  further  remembered,  how  insidious  and  dif- 
ficult of  explanation  many  of  the  symptoms  of 
these  diseases  are,  and  how  apt  they  are  to  be 
mistaken  for  other  affections,  the  value  of  Mr. 
Burns’  work  will  be  duly  appreciated.  The 
valuable  work  of  Corvisart  on  this  subject, 
which  was  published  in  France  about  the  same 
time,  may  be  considered,  in  connexion  with  Mr 
Burns’  book,  as  fixing  an  important  era  in  the  his- 
tory of  these  most  important,  and,  heretofore,  ill- 
understood  diseases.  Both  works  possess  many 
and  peculiar  excellencies;  but  I trust  I shall  not  be 
accused  of  permitting  the  feelings  of  friendship 
to  influence  my  judgment,  when  I give  it  as  my 
opinion,  that,  as  a book  of  practical  observation 
and  philosophical  explanation  of  the  causes  of 
symptoms,  from  anatomical  connexions  and  change 
of  structure,  the  treatise  of  Mr.  Burns  is  de- 
cidedly superior  to  the  one  published  by  the 
Parisian  Professor. 

The  second  of  Mr.  Burns’  great  works  is  now 
presented  to  the  American  public.  It  has  been  con- 
sidered by  Sir  Astley  Cooper,  Mr.  Abernethy, 
and  the  other  distinguished  public  teachers  of  Lon- 


LIFE  OF  THE  AUTHOR. 


XX111 


don,  as  well  as  by  those  in  other  parts  of  Great 
Britain  as  one  of  the  very  best  books  on  surgical 
anatomy,  and  that  it  will  obtain  the  same  rank  in 
this  country,  I cannot  doubt.  In  doing  justice  to 
the  author,  it  should  be  recollected,  that  the 
plan  of  writing  general  observations  on  surgery 
with  anatomical  descriptions,  is  in  a great  measure 
peculiar  to  himself.  Since  his  time,  this  has 
become  general,  and  its  excellency  is  now  univer- 
sally admitted. 

Mr.  Burns’  style,  as  a writer,  is  far  from  being 
free  from  defects.  Accustomed  from  very  early 
youth  to  the  habit  of  extemporaneous  speaking,  he 
acquired  a rapidity  of  expression,  which,  although 
sufficiently  correct  for  the  purposes  of  oral  de- 
monstration, was  too  diffuse  and  colloquial 
for  written  compositions.  Yet,  although  his 
manner  is  far  from  being  critically  correct,  there 
is  still  a vividness  and  perspicuity  in  his  descrip- 
tions, which  repays  us  for  their  want  of  elegance. 

It  is  very  justly  observed  by  Mr.  Burns’  re- 
viewers, that  “a  more  zealous  and  eloquent  teacher 
was  never  known.”  Possessing  the  most  perfect 
knowledge  of  his  subject,  he  was  never  at  a loss 
in  his  descriptions,  nor  in  want  of  materials  for 
the  illustration  or  elucidation  of  his  subject.  He 


XXIV 


LIFE  OF  THE  AUTHOR. 


had  likewise  a most  happy  talent  for  arresting 
the  attention,  and  of  throwing  around  the  most 
dry  demonstrations  a charm  of  which  they  could 
hardly  be  supposed  to  be  susceptible.  For  per- 
spicuity he  had  certainly  no  equal.  The  most 
intricate  subject  became,  from  the  lucid  order  he 
pursued  in  their  demonstration,  clear  and  simple. 

Mr.  Burns’  temper  was  warm,  perhaps  irasci- 
ble, his  passion  however  was  but  for  a moment;  and 
if,  under  its  influence,  he  did  any  one  an  injury, 
he  was  the  first  to  confess  it  and  make  ample  re- 
paration. In  his  intercourse  with  mankind,  he 
was  a perfect  gentleman.  To  his  friends  his  man- 
ners were  most  endearing.  Destitute  of  every 
selfish  feeling,  he  had  their  interests  more  at 
heart  than  his  own,  and  for  them  he  was  at  all 
times  ready  to  make  any  personal  sacrifice.  For 
four  years  I was  scarcely  an  hour  separated  from 
him,  and  it  is  now  with  feelings  of  gratitude  I ac- 
knowledge, that  if  I have  been  at  all  successful, 
either  as  a Practitioner  or  Public  Teacher,  it  is 
to  his  example  and  friendly  instruction  I am  in  a 
very  great  measure  indebted  for  my  success. 


AUTHOR’S  PREFACE 


TO  THE 

jmst  ismtfmu 

In  the  following  work  it  has  been  my  object  to 
describe  the  Surgical  Anatomy  of  the  Head  and 
Neck.  I have  not,  however,  entirely  confined  my 
attention  to  the  anatomy  of  the  head  and  neck, 
and  to  the  practical  deductions  from  that  alone; 
but,  on  the  contrary,  I have  entered  pretty  fully 
into  the  consideration  of  the  general  principles 
which  ought  to  regulate  us  in  the  treatment  of 
some  diseases  incident  to  the  neck,  in  common 
with  other  parts  of  the  body.  This  I have  espe- 
cially done  in  regard  to  Aneurism,  the  practical 
doctrines  of  which  I have  examined,  and,  in 
some  instances,  freely  criticised.  I have  also 
entered  occasional  remarks  on  the  nature  of  tu- 
mours, but  these  are  very  cursory  and  limited. 
They  are,  however,  as  full  as  I thought  my  object 
in  introducing  them  required. 

4 


xxvi 


author’s  preface. 


In  the  following  pages,  I have  treated  the 
names  of  some  of  the  promoters  and  improvers 
of  our  art  with  freedom;  but,  I trust,  on  no  occa- 
sion with  disrespect.  I have  combated  opinions, 
but  never  because  they  belonged  to  this  or  to  that 
author,  but  because  I believed  them  to  be  erro- 
neous. 

In  executing  the  surgical  part  of  this  book  I 
have  collected  my  facts  from  various  sources, 
W'hich  I have  generally  acknowledged;  but  in 
regard  to  the  anatomical  part,  there  are  few  de- 
scriptions introduced  which  have  not  been  given 
from  numerous  observations  and  dissections  made 
by  myself.  I would  also  wish  it  to  be  understood 
that  I have  never  described  the  relative  anatomy 
of  a part,  from  any  individual  subject;  on  the 
contrary,  each  description  has  been  drawn  up 
from  the  inspection  of  many  bodies. 

In  doing  this,  the  points  wherein  these  corres- 
ponded were  noted,  and  assumed  as  a standard, 
and  the  anomalies,  w7here  of  practical  importance, 
were  not  overlooked.  Most,  however,  of  what 
relates  to  varieties  in  the  origin  and  position  of 
t!  e arteries,  has  already  been  made  public  in  a 
paper  on  that  subject,  contained  in  a book  which 
I lately  published  on  the  Diseases  of  the  Heart. 


author’s  preface.  xxvii 

For  every  quotation,  therefore,  from  that  work,  I 
consider  the  present  acknowledgement  sufficient. 

To  obtain  correct  anatomical  descriptions,  and 
to  deduce  from  them  just  practical  conclusions, 
has  been  my  anxious  endeavour;  how  far  I have 
succeeded  in  the  execution  of  this  part  of  my 
plan,  belongs  to  others  to  decide.  I may,  how- 
ever, with  propriety,  mention,  that  the  descrip- 
tions are  not  the  result  of  hasty  examinations; — 
they  were  sketched  six  years  ago,  during  which 
time  I have  carefully  compared  many  subjects, 
and  added  cases  in  illustration  as  they  occurred. 

The  present  volume  has  no  pretensions  to  more 
than  merely  containing  a few  hints,  and  these  not 
always  in  very  regular  order,  of  the  most  import- 
ant, surgical  anatomy  of  the  head  and  neck — hints 
which  I hope  will  be  found  useful  by  the  student, 
but  most  of  which  are  probably  familiar  to  the 
experienced  practitioner.  It  will  be  found  very 
different  from  the  elementary  works  on  anatomy, 
which  are  required  to  initiate  the  student  to 
names  and  individual  parts: — the  present  obser- 
vations being  intended  to  introduce  him  to  the 
contents  of  regions. 

As  a book  of  this  nature  would  be  of  no  value, 
without  sketches  to  illustrate  the  descriptions. 


xxviii  author’s  preface. 

Mr.  William  P.  Hodge,  of  St.  Eustatius’,  an  in- 
dustrious pupil  of  mine,  has  had  the  goodness  to 
give  his  assistance  in  this  department.  As  all 
of  the  drawings  were  made  under  my  own  inspec- 
tion, and  by  one  acquainted  with  the  anatomy  of 
the  parts  he  was  delineating,  I flatter  myself  they 
will  be  found  faithful  copies  of  nature.  Some  of 
them  are  mere  sketches,  others  are  more  finished 
drawings;  but  in  no  instance  have  we  ever  sacri- 
ficed accuracy  of  representation  for  beauty  of 
execution. 

It  has  been  mentioned  by  some  authors,  that  to 
render  plates  really  useful,  the  parts  ought  to  be 
of  their  natural  size;  but  this  I have  never  con- 
sidered essential.  Drawings,  I am  convinced, 
may  be  employed  advantageously  of  any  size, 
provided,  in  reducing  them,  the  proportion  of  the 
different  parts  be  justly  preserved;  and  I am 
equally  persuaded,  that  in  delineation  of  natural 
texture,  it  is  not  necessary  to  colour  the  bones, 
muscles,  vessels,  and  nerves.  Camper,  by  a few 
well  chosen  lines,  has,  in  his  inimitable  plates, 
expressed  more  than  many  modern  artists  do, 
with  their  varied  tints  and  complicated  shading. 
A highly  finished  drawing  certainly  does  please 
the  eye  more  than  an  unpolished  sketch;  but  in 


author’s  preface. 


xxix 


the  former,  it  is  to  be  remembered,  that  boldness 
and  accuracy  are  often  sacrificed  to  elegance. 

With  these  remarks  I lay  the  following  Obser- 
vations before  the  public,  with  an  anxious  wish 
that  they  may  prove  useful  to  the  student  and 
young  surgeon,  for  whom  they  are  chiefly  inten- 
ded. They  may,  perhaps,  lead  him  to  combine 
circumstances,  and  to  judge  from  these  how  far 
an  operation  would  be  advisable,  in  any  indivi- 
dual case;  or  they  may  put  him  on  his  guard 
against  undertaking  rashly,  an  operation  with 
which,  had  he  been  better  acquainted  with  the 
group  of  parts  concerned,  he  would  prudently 
have  declined  interfering.  If,  indeed,  in  any 
way,  he  find  them  useful  to  him,  I shall  not 
view  the  time  employed  in  arranging  them  as 
mispent. 


Glasgow , 10 th  October , 1811. 


OBSERVATIONS 


ON  THE 

SURGICAL  ANATOMY 


OF  THE 


In  works  on  Anatomy,  each  separate  system 
is  generally  considered  apart,  and  without  a re- 
ference to  the  others;  and  in  surgical  books,  it 
is  presumed  that  the  student  has  already  acquired 
a sufficient  knowledge  of  the  structure  of  the 
human  body.  Although  we  have,  perhaps,  little 
reason  to  complain  of  the  want  of  tolerably  accu- 
rate descriptions  of  the  bones,  the  muscles,  the 
blood  vessels,  the  nerves,  the  absorbent  system, 
and  the  glands;  still,  this  to  the  operator  is  not 
sufficient.  It  requires  a greater  degree  of  dis- 
crimination, and  a more  accurate  conception  of  the 
parts,  than  most  students,  nay,  I believe,  than 
most  surgeons  possess,  to  be  able  to  combine  these 
disjointed  lessons,  so  as  to  form  from  them  a useful 


32 


ON  THE  SURGICAL  ANATOMY 


and  connected  whole.  I am  afraid,  that  in  plan- 
ning operations,  the  surgeon,  too  frequently,  pro- 
ceeds on  a limited  view  of  the  parts  amongst 
which  he  has  to  cut.  More  than  once  I have 
heard  the  propriety  of  an  operation  argued  from 
the  inspection  of  a mere  blood  vessel  dried  pre- 
paration;— a guide  surely  more  liable  to  mislead, 
than  to  lead  to  a rational  practice.  The  blood 
vessels  are,  no  doubt,  highly  necessary  to  be  per- 
fectly understood,  but  this  knowledge,  to  be  prac- 
tically useful,  must  be  conjoined  with  a compre- 
hensive acquaintance  with  the  neighbouring  parts. 
On  this  account,  I endeavour  to  connect  the  de- 
monstrations of  the  arteries,  with  the  local  struc- 
ture of  the  muscles,  nerves,  and  glands,  and  with 
the  performance  of  surgical  operations.  That 
this  is  the  most  advisable  plan  of  teaching  the 
student  the  true  value  of  anatomy,  few  will  dis- 
pute; but  I fear  that  the  execution  will  not  prove 
equal  to  the  design. 

In  attending  to  the  general  structure  of  the 
neck,  the  platysma  myoides  and  the  fascia  must 
be  first  considered,  for  both  have  a share  in 
modifying  disease.  The  platysma  myoides  lies 
immediately  below  the  skin  and  cellular  mem- 
brane. It  is  often  composed  of  a slender  set  of 
pale  scattered  fibres,  but  sometimes,  and  espe- 
cially in  short  thick-necked  males,  it  forms  a 
strong  muscular  defence  to  the  throat.  It  covers 
the  front  and  sides  of  the  neck,  is  attached  to  the 


OF  THE  HEAD  AND  NECK. 


33 


cellular  membrane  lying  over  the  jaw  bone,  and 
is  indistinct  at  its  termination,  where  it  is  incor- 
porated with  the  fat  and  fascial  muscles.  No 
doubt,  as  this  muscle  is  attached  to  the  integu- 
ments, it  can  wrinkle  the  skin  of  the  neck,  as  in 
rage,  or  depress  the  angles  of  the  mouth,  as  in 
grief;  but  these  are  subordinate  and  accidental 
offices  performed  by  this  muscle,  whose  chief  use 
is  surely  to  support  the  deep  seated  parts.  Be- 
sides the  platysma  myoides,  the  throat  is  covered 
by  an  aponeurosis  or  fascia.  My  attention  was  first 
called  to  this  fascia  about  seven  years  ago,  during 
the  dissection  of  an  emaciated  anasarcous  subject, 
in  which  it  was  nearly  as  strong  as  the  fascia  of 
the  limbs.  Since  that  time,  I have  uniformly  de- 
monstrated it  in  every  course. 

The  cervical  fascia  in  its  natural  state  is  thin, 
but  even  in  this  condition,  it  is  more  resisting 
than  its  texture  would  lead  us  to  suppose.  To 
see  it  where  it  is  really  an  object  of  interest  to 
the  surgeon,  we  must  contemplate  it  where  thick- 
ened by  the  pressure  of  tumours  formed  beneath 
it.  If  we  do  this,  we  shall  be  convinced,  that 
both  it  and  the  platysma  myoides  perform  the 
office  of  fasciae,  and  we  shall  at  once  be  satisfied 
that  the  neck,  so  far  from  being  without  a fascia, 
is  provided  with  a double  sheath;  a fact  which 
cannot  be  too  firmly  impressed  on  the  mind  of  the 
student.  It  will  lead  him  to  form  a just  estimate 
of  the  nature  of  some  diseases,  and  will  assist  him 
5 


34 


ON  THE  SURGICAL  ANATOMY 


in  explaining  the  causes  of  particular  symptoms. 
Nor  is  it  sufficient  that  it  be  known  that  the  neck 
is  invested  with  a fascia;  there  are  likewise  pecu- 
liarities in  its  mechanism,  at  different  parts,  which 
must  be  pointed  out. 

The  fascia  of  the  neck  descends  from  the  lower 
edge  of  the  maxilla  inferior,  and  is  thinner  at  the 
front  than  at  the  angle  of  the  jaw.  At  that  part, 
a fold  of  the  fascia  is  tucked  back  to  the  styloid 
process,  to  which  it  adheres,  and  here  it  is  incor- 
porated with  an  aponeurotic  expansion  from  the 
pterygoid  muscle,  forming  the  ligament  of  the 
jaw.  This  ligament  may  readily  be  felt,  chord- 
like, extending  from  behind  the  angle  of  the  jaw 
backward  and  downward.  It  is  rendered  distinct, 
by  bending  back  the  head,  and  inclining  it  to  the 
side  opposite  the  one  we  are  to  examine.  In 
emaciated  bodies,  it  forms  a stringy  line,  which 
seems  to  be  lost  about  the  anterior  margin  of  the 
sterno-mastoid  muscle.  The  fascia,  as  it  descends 
along  the  neck,  dips  down  among  the  muscles  and 
glands,  forming  capsules  for  the  latter.  These  are 
productions  from  the  inner  surface  of  the  fascia, 
in  the  same  way  that  the  falx  is  a production  from 
the  dura  mater.  On  its  outer  surface  the  fascia 
is  pretty  smooth,  and  it  is  nearly  of  uniform  thick- 
ness in  every  part  below  the  os  hyoides,  till  it  comes 
to  expand  over  the  pectoral  muscle,  when  it  puts 
on  more  of  a cellular  appearance.  At  the  lower 
part  of  the  throat,  there  is  some  peculiarity  in 


OF  THE  HEAD  AND  NECK. 


35 


the  mechanism  of  the  fascia.  When  the  integu- 
ments are  dissected  off,  the  fascia,  which  has  been 
described,  is  brought  into  view,  covering  the 
sterno-mastoid  muscles,  and  extended  between 
their  tendons.  By  dividing  this  fascia,  a mass  of 
fat,  equally  thick  as  the  upper  bone  of  the  ster- 
num, and  often  having  imbedded  in  its  substance 
a small  conglobate  gland  is  brought  into  view. 
When  these  are  cleared  away,  another  layer  of 
firm,  tense,  and  fibrous  fascia,  is  exposed  cover- 
ing the  outer  surface  of  the  sterno-hyoid  and  thy- 
roid muscles.  By  pulling  the  superficial  fascia, 
the  deep  seated  one  will  be  seen  to  be  derived 
from  it.  Where  the  fold  from  the  superficial  fas- 
cia is  inflected  along  the  upper  end  of  the  ster- 
num, it  is  greatly  strengthened  by  the  crossings 
and  bindings  of  strong  tendinous  fibres.  The  deep 
fascia  over  the  sterno-hyoid  muscles,  is  much 
stronger  than  the  superficial  fascia;  indeed  it  for- 
cibly resists  any  effort  to  push  the  finger  through 
it  into  the  chest.  It  likewise  prevents  the  finger 
being  pushed  from  the  chest  higher  than  the 
lower  edge  of  the  thyroid  gland.  These  are  facts 
which  I would  wish  to  impress  on  the  mind,  for 
they  are  highly  necessary  to  be  remembered. 
The  first  will  assist  us  in  explaining  the  use  of 
these  fasciae  and  muscles,  while  the  second  leads 
to  an  illustration  of  some  morbid  phenomena. 

From  what  takes  place  on  the  removal  of  the 
superficial  and  deep  fasciae,  accompanied  with 


36 


ON  THE  SURGICAL  ANATOMY 


destruction  of  the  stern o-hyoid  and  thyroid  mus- 
cles, we  learn  the  value  of  them.  So  long  as  these 
remain  entire,  breathing  is  performed  with  ease, 
provided  there  be  no  disease  in  the  lungs,  or 
neighbouring  parts;  but  whenever  these  fasciae 
and  muscles  are  removed,  then,  on  every  attempt 
to  increase  the  size  of  the  chest,  the  atmospheric 
air  pushes  back  the  unresisting  skin  on  the  tra- 
chea, compressing  that  tube  to  such  a degree,  as 
to  occasion  very  serious  difficulty  in  breathing. 
The  sterno-hyoid  and  thyroid  muscles  are  capable 
of  steadying  the  hyoid  bone  and  thyroid  cartilage, 
or  of  depressing  these  parts;  but  their  great  use  is 
to  co-operate  with  the  fasciae,  in  preventing  the 
gravitation  of  the  air  on  the  windpipe.  That  this 
is  a correct  account  of  their  office,  will  be  illustra- 
ted by  the  following  case,  which  was,  some  time 
ago,  under  the  care  of  Dr.  Brown,  by  whose 
kindness  I had  an  opportunity  of  seeing  the  pa- 
tient, and  taking  a cast  from  the  parts.  The 
gentleman  was  between  twenty  and  thirty.  He 
had  the  hooping-cough  when  three  years  of  age; 
the  disease  was  pretty  severe,  and  ever  after- 
wards he  experienced  some  difficulty  in  breathing, 
but  till  within  these  few  years,  there  was  no  exter- 
nal mark  of  disease.  About  that  time  he  perceived 
a fulness  and  tension  just  above  the  sternum, 
which  increased  during  three  months,  when  the 
integuments  burst,  and  a quantity  of  fluid  was 
discharged.  The  ulcer  soon  put  on  a decidedly 


OF  THE  HEAD  AND  NECK. 


37 


scrophulous  appearance,  and  from  it  the  patient 
drew  out  from  between  the  laminse  of  the  medias- 
tinum, a portion  of  lymphatic  substance  about 
three  inches  in  length.  Soon  after  this  the  sore 
began  to  skin  over,  but  without  restoration  of  the 
lost  substance.  After  the  opening  was  complete- 
ly closed,  the  trachea,  the  arteria  innominata, 
and  the  thyroid  branch  of  the  lower  thyroid  ar- 
tery, were  found  to  be  covered  merely  by  a very 
thin  pelicle  of  polished  skin, — a defence  not  suf- 
ficient to  prevent  the  pressure  of  the  air  on  the 
trachea;  consequently,  whenever  this  person,  by 
increasing  the  size  of  the  chest,  forms  a vacuum 
in  the  trachea,  the  air  passes  into  its  canal  in  part 
by  the  rima  glottidis,  but  it  likewise  endeavours 
to  force  its  way  directly  above  the  sternum.  The 
fasciae  and  muscles  being  destroyed,  the  mecha- 
nical pressure  of  the  atmosphere  compresses,  to  a 
certain  degree,  the  canal  of  the  windpipe. 

On  this  case  I would  remark,  that  there  is 
reason  to  believe,  that  the  irritation  excited  in 
the  thorax,  during  the  hooping-cough,  had  begun 
the  disease  in  the  thymus  gland,  which  had  con- 
tinued slowly  to  increase,  till,  at  last,  an  abscess 
formed  in  it.  If  this  be  a correct  supposition,  we 
learn  why  the  breathing  has  been  uniformly  diffi- 
cult from  the  time  he  had  the  hooping-cough,  even 
to  the  present  day.  Previous  to  the  formation  of 
abscess  in  the  gland,  it  is  probable  that  it  had 
been  enlarged,  and  that  it  had,  by  its  mechanical 


38 


ON  THE  SURGICAL  ANATOMY 


pressure  on  the  trachea,  produced  dyspnoea. — 
After  the  healing  of  the  ulcer,  which,  in  its  pro- 
gress, had  destroyed  both  the  fascia  and  muscles, 
no  one  can  wonder  that  there  should  be  great  dif- 
ficulty in  breathing.  The  destruction  of  these 
parts,  and  the  matting  about  the  top  of  the  chest, 
afford  a satisfactory  explanation  of  the  cause  of 
this.  By  the  loss  of  the  former,  the  resistance  to 
the  air  being  removed,  there  is  at  each  time  that 
the  patient  inspires,  a deep  hollow  formed  at  the 
upper  part  of  the  sternum,  and  a wheezing 
sound  is  produced  by  the  passage  of  the  air  along 
the  narrowed  trachea.  I have  often  thought,  but 
have  had  no  opportunity  to  put  it  to  the  test  of 
experiment,  that  by  artificially  supplying  the  lost 
parts,  we  might  alleviate  the  difficulty  of  breath- 
ing. This  might  be  done  by  applying  a piece  of  lea- 
ther, spread  with  adhesive  plaster,  over  the  lower 
part  of  the  neck,  taking  care  to  place  it  there 
while  the  patient  was  in  the  act  of  expelling  air 
from  the  lungs.  By  pressure  with  the  hand,  it 
might  be  retained  in  a proper  situation,  till  it  was 
so  fixed  as  not  to  be  forced  back  by  the  atmos- 
phere. To  prevent  the  starting  of  the  edges  of 
the  leather,  and  the  insinuation  of  the  air  be- 
tween the  skin  and  the  plaster,  they  might  both 
be  brushed  over  with  a solution  of  sealing  wax 
in  alcohol,  as  recommended  by  Mr.  Abernethy 
after  operations  on  the  knee  joint. 


OF  THE  HEAD  AND  NECK. 


39 


The  structure  of  the  fascia  and  muscles  is  next 
to  be  attended  to,  as  illustrating  disease.  The 
thymus  gland,  which  is  in  a manner  peculiar  to 
young  animals,  is  lodged  between  the  layers  of 
the  anterior  mediastinum  immediately  behind 
the  sternum,  and  lying  over  the  forepart  of  the 
arch  of  the  aorta,  the  roots  of  its  primary  trunks 
and  the  subclavian  vein,  between  which  and-  the 
spine,  the  trachea  and  oesophagus  are  placed. 

This  gland  is  apt  to  enlarge  in  those  of  a pecu- 
liar habit,  and  its  position  is  such,  that  whenever 
it  begins  to  swell,  it  occasions  most  serious  unea- 
siness. On  the  front  the  tumour  is  prevented  by 
the  sternum  from  protruding  outwardly;  above  the 
sternum,  the  fascia  and  muscles  repress  its  growth; 
as  it  enlarges,  therefore,  it  must  press  backwards 
on  the  important  parts  which  are  between  it  and 
the  spine.  No  wonder,  then,  that  the  patient 
should  in  the  end,  die  from  suffocation  and  star- 
vation. Even  what  food  passes  into  the  stomach, 
fails  to  nourish  the  body  properly.  The  pressure 
of  the  tumour  on  the  subclavian  vein,  interrupts 
the  entrance  of  the  chyle  into  the  heart,  and 
thence  the  mesenteric  glands  are,  in  such  cases, 
generally  found  enlarged  and  obstructed.  In 
three  children  who  had  died  from  disease  of  the 
thymus  gland,  I found  the  lacteal  gland  increased 
in  size.* 


* There  is  no  doubt  that  marasmus  of  the  system  is  generally  present 
in  those  cases, -where  the  thymus  gland  is  affected  with  the  enlargement 


40 


ON  THE  SURGICAL  ANATOMY 


As  this  disease  generally  occurs  in  children  of 
a scrophulous  constitution,  I have  repeatedly  pre- 
scribed muriate  of  lime,  burnt  sponge,  and  the 
other  remedies  usually  employed  in  that  disease, 
but  have  never  seen  them  of  advantage.  I have 
witnessed  decidedly  good  effects  from  repeated 
blisters  and  long  continued  friction,  but  even 
these  seldom  do  more  than  merely  alleviate,  and 
that  only  before  tabes  mesenterica  has  been  in- 
duced. 

When  topical  and  internal  remedies  have  failed, 
it  is  practicable,  although  many  may  be  inclined 
to  think  not  prudent,  to  remove  the  gland. — 
Where  the  thymus  is  so  much  enlarged  as  to  give 
rise  to  serious  symptoms,  a fulness  and  swelling  is 
felt  above  the  sternum,  where  it  is  only  covered 
by  the  fascia,  and  sterno-hyoid  and  thyroid  mus- 
cles. After  death  I have  twice  removed  the 
tumour.  To  do  this,  I made  an  incision  on  the 
front  of  the  neck,  just  above  the  sternum,  and  be- 
tween the  sterno-hyoid  muscles,  as  in  the  opera- 

described  in  the  text,  but  the  explanation  of  the  cause  of  this  emaciation 
given  by  the  author,  is  by  no  means  satisfactory.  I have  dissected  many 
cases  of  this  disease,  and  have  never  met  with  one  in  which  the  transverse 
vein  had  become  obliterated.  But,  even  allowing  that  the  pressure  of  the 
tumor  did  close  that  vessel,  still  its  blood  mixed  with  the  chyle,  would  enter 
the  circulation  by  anastomosis.  It  is  probable  that  the  tabes  mesenterica, 
and  the  disease  of  the  thymus  gland,  commence  at  the  same  time,  and  ori- 
ginate from  the  same  cause, — a scrophulous  disposition  of  the  system.  If 
this  opinion  be  correct,  the  operation  recommended  for  the  removal  ot  the 
thymus  gland,  although  it  might  relieve  the  dyspnoea,  could  in  no  case 
restore  the  patient  to  health;  the  diseased  enlargemeut  of  the  mesenteric 
glands  remaining,  would  speedily  destroy  life. — Ed. 


OP  THE  HEAD  AND  NECK. 


41 


tion  of  tracheotomy.  By  this  cut,  the  rounded 
knob  of  the  diseased  thymus  was  exposed.  Hav- 
ing done  this,  I next  insinuated  the  fore  finger 
between  the  gland  and  the  adjacent  parts,  till  the 
former  was  insulated  so  far  as  I could  reach.  Af- 
ter this,  by  a pair  of  polypi  forceps,  cautiously  in- 
troduced between  the  mediastinum  and  the  gland, 
I grasped  the  tumour,  and  wrenched  it  from  its 
connexions.  This,  on  the  living  subject,  would  be 
a most  dangerous  operation,  yet  where  death  is 
otherwise  inevitable,  it  might  perhaps  be  war- 
rantable to  try  it.  I think,  that  were  it  cautious- 
ly executed,  injury  of  the  large  vessels  might  be 
avoided,  and  the  sponge  would  easily  command 
any  bleeding  which  might  take  place  from  its  own 
nutrient  arteries;  an  event  which  is  hardly  possi- 
ble, if  the  tumour  be  pulled  away.  Some  may 
suppose,  that  inflammation  woidd  be  apt  to  follow 
this  operation,  but  this  is  to  be  little  dreaded;  the 
debilitated  state  of  the  patient  will  be  a sufficient 
security  against  its  occurrence. 

It  has  been  mentioned,  that  one  or  more  conglo- 
bate glands  generally  lie  imbedded  among  the 
loose  fat  and  thready  cellular  substance  which 
occupies  the  space  between  the  two  plates  of  fas- 
cia. Where  these  glands  enlarge,  they  form  a 
tumour,  in  many  respects  resembling  a diseased 
thymus,  but  by  attention,  the  one  disease  may 
be  easily  distinguished  from  the  other.  Enlarge- 
ment to  the  same  degree  of  the  thymus,  would  be 
6 


42 


ON  THE  SURGICAL  ANATOMY 


productive  of  most  serious  dyspnoea,  but  swelling 
of  the  lymphatic  gland,  although  productive  of 
difficulty  in  breathing,  does  not,  till  very  large, 
endanger  the  life  of  the  patient.  Besides,  by  ex- 
amination, it  can  generally  be  ascertained,  that 
such  a tumour  is  unconnected  with  the  chest.  My 
friend,  Dr.  Gordon,  Lecturer  on  Anatomy  and 
Physiology  in  Edinburgh,  very  lately  met  with  an 
instance  of  enlargement  of  this  gland,  in  a patient 
who  had  died  from  tetanus.  Mr.  Cruikshanks 
saw  a fatal  case  of  this  disease.  As  the  tu- 
mour is  exterior  to  the  deep  fascia  and  muscles, 
there  can  be  no  reason  why  it  should  not  be  ex- 
tirpated; it  is  not  connected  with  any  vessel  or 
nerve  of  importance,  and  can,  on  cutting  into  its 
capsule,  be  easily  started  from  its  seat. 

Besides  these  glands,  there  are  many  other 
conglobate  glands  about  the  neck  and  throat.  Of 
these,  some  lie  more  superficial,  and  others  deeper 
seated  than  the  fascia  This,  therefore,  leads  to  a 
natural  division  of  tumours  about  the  throat,  into 
those  which  are  covered  by  the  fascia,  and  into 
those  which  lie  exterior  to  it.  This  is  a distinction 
of  practical  importance.  Tumours  by  being  placed 
more  superficial,  or  deeper  than  the  fascia,  are 
modified  in  their  complexion,  varied  in  their 
effect,  and  more  or  less  difficult  in  their  removal. 
As  may  naturally  be  supposed,  those  tumours 
which  form  exterior  to  the  fascia,  are  superficial, 
moveable,  and  as  they  enlarge,  spread  laterally, 


OF  THE  HEAD  AND  NECK. 


43 


and  even  when  of  great  size,  are  comparatively 
easily  extirpated.  They  are  circumscribed,  ele- 
vated, and  for  a length  of  time,  by  grasping  them, 
we  can  pull  them  so  far  outward,  as  to  allow,  in 
some  degree,  of  the  insinuation  of  the  finger  be- 
tween them  and  the  parts  behind. 

It  is  of  consequence  to  extirpate  such  tumours, 
so  soon  as  we  have  ascertained  that  they  are  of  a 
nature  requiring  removal,  for  although  they  at 
first  lie  exterior  to  the  fascia,  yet  in  the  progress 
of  their  enlargement,  they  press  on  this  sheath, 
producing  thickening  and  adhesion  of  it  to  them- 
selves, and  the  parts  below;  or  at  other  times  the 
pressure  is  productive  of  absorption  of  the  inter- 
posed layer  of  fascia,  after  which  the  tumour,  as 
if  it  had  originally  been  placed  beneath  the  fascia, 
dips  backward,  and  contracts  adhesion  to  the 
deeper  and  more  important  parts.  These  tu- 
mours do  not,  however,  invariably  produce  either 
of  the  effects  described.  Sometimes  even  where 

t 

very  large,  they  remain  free  from  adhesion  to  the 
parts  behind. 

A man,  ten  months  ago,  while  in  the  West  In- 
dies, observed  a small  moveable  tumour  at  the 
angle  of  the  jaw,  not  larger  at  first  than  a horse 
bean,  and  productive  of  very  little  inconvenience. 
As  it  evidently  continued  to  increase,  he  was 
advised  to  leave  the  country,  in  order  to  get  the 
diseased  parts  extirpated  in  a colder  climate. 
With  a view  to  this  he  came  to  Glasgow.  When 


44 


ON  THE  SURGICAL  ANATOMY 


1 saw  him,  the  tumour  was  about  the  size  of  the 
head  of  a new  born  child,  was  situated  over  the 
lowest  part  of  the  parotid  gland,  and  over  the 
sterno- mastoid  muscle,  was  regular  on  its  sur- 
face, elastic  to  the  touch,  and  only  painful  at 
one  particular  spot,  unless  when  pressed  on, 
at  which  time  he  complained  of  a diffused,  al- 
though not  acute  pain,  over  the  whole  extent  of 
the  tumour.  It  neither  gave  rise  to  inconveni- 
ence in  breathing  nor  swallowing,  nor  impeded 
the  motion  of  the  jaw,  and  when  grasped  between 
he  fingers,  it  could  be  pulled  out  from  its  attach- 
ments behind;  a clear  proof  that  it  was  still  un- 
connected with  any  part  which  would  render  its 
extirpation  hazardous. 

This  tumour,  I have  no  doubt,  originally  arose 
from  enlargement  of  one  of  the  subcutaneous  lym- 
phatic glands,  and  I believe  that  it  will  generally 
be  found,  that  such  swellings,  from  the  small 
quantity  of  interstitial  fluid  which  they  contain, 
are  firm  and  unyielding,  or  only  slightly  elas- 
tic. They  are  commonly  called  wens:  when  cut 
into,  they  appear  as  if  composed  of  a mixture 
of  cellular  membrane,  and  intervertebral  sub- 
stance. They  are  very  indolent,  have  few 
blood  vessels,  and  very  few  fibrillse  of  nerves  can 
be  traced  into  their  substance:  of  consequence, 
they  are  torpid,  and  even  when  large,  produce 
only  a dull  heavy  sensation,  not  generally  amoun- 
ting to  pain,  Such  tumours  seldom  suppurate, 


OF  THE  HEAD  AND  NECK. 


45 


but  sometimes  by  their  irritation,  they  excite  in- 
flammation in  the  parts  with  which  they  are  in 
contact.  This  deprives  them  of  their  due  supply 
of  blood,  they  die,  and  I have  seen  the  body  of 
the  tumour  when  the  skin  which  covered  it  gave 
way,  cast  off  as  an  extraneous  substance.  In  this 
way  a natural  cure  is  sometimes  accomplished,  but 
it  is  a rare  occurrence.  Where  the  tumour  is  nei- 
ther extirpated,  nor  otherwise  destroyed,  it  con- 
tinues progressively  to  increase  in  size;  and  often 
when  it  has  continued  for  a length  of  time,  its  ves- 
sels assume  a new  mode  of  acting,  they  form  a 
pretty  solid  substance,  sometimes  cartilaginous, 
and  at  other  times  osseous. 

Mr.  Travers,  Demonstrator  of  Anatomy  in 
Guy’s  Hospital,  writes  me,  that  Mr.  Astley  Coop- 
er, some  time  ago,  extirpated  three  large  tu- 
mours of  this  kind,  from  about  the  angle  of  the 
jaw.  In  his  cases,  the  tumours  began  just  below 
the  zygoma,  they  descended  considerably  lower 
than  the  angle  of  the  jaw  and  extended  forward 
till  they  readied  the  spot  where  the  fascial  artery 
makes  its  turn  over  the  jaw,  and  posteriorly  they 
included  the  lobe  of  the  ear.  They  were,  as  Mr. 
Travers  observes,  in  their  external  features, 
such  as  would  generally  deter  country  practition- 
ers from  interfering  with  them.  Their  extirpa- 
tion is  extremely  simple,  they  have  seldom,  even 
when  large,  above  a single  artery  of  such  a size  as 
to  require  a ligature,  entering  into  their  sub- 


46 


ON  THE  SURGICAL  ANATOMY 


stance.  The  veins,  however,  belonging  to  the 
tumour  are  often  varicose,  so  that  when  divided, 
they  pour  out  a considerable  quantity  of  blood. — 
This  is  the  only  inconvenience  which  generally 
attends  the  extirpation  of  such  tumours. 

In  extirpating  a tumour  of  this  kind,  it  is  ad- 
vantageous not  to  leave  too  much  skin.  Where, 
therefore,  the  swelling  is  large,  even  although  the 
integuments  be  not  diseased,  a portion  of  the  skin 
must  be  removed  by  an  elliptical  incision.  Then, 
by  dissection,  the  whole  extent  of  the  tumour  to 
its  base,  is  to  be  fairly  exposed,  after  which,  it  is 
to  be  grasped  with  the  left  hand,  and  pulled  out- 
ward, while,  with  the  scalpel,  its  cellular  connex- 
ion with  the  fascia  is  to  be  divided.  Where  the 
tumour  is  small,  it  is  preferable,  when  the  whole 
of  it  is  uncovered,  to  grasp  it  firmly  between  the 
fingers,  and  suddenly,  with  a twisting  motion, 
wrench  it  from  its  place.  This  possesses  several 
advantages  over  the  use  of  the  knife;  we  do,  in- 
deed, occasion  a more  pungent  pain  by  the  for- 
mer, but  then  it  is  of  less  duration,  and  we  sel- 
dom or  never  have  any  bleeding  from  lacerated 
vessels. 

I have  seen  a subcutaneous  tumour  over  the 
parotid  gland,  when  not  larger  than  a walnut,  by 
its  pressure,  produce  absorption  of  a part  of  the 
parotid,  by  which  it  made  a bed  for  itself  in  the 
substance  of  the  gland.  In  such  a case,  it  is  evi- 
dent that  it  would  be  very  difficult  to  dissect 


OP  THE  HEAD  AND  NECK. 


4? 


away  the  tumour  with  the  knife,  without,  at  the 
same  time,  injuring  the  parotid,  which  is  avoided 
by  tearing  away  the  tumour  with  the  fingers. 

After  the  tumour  has  been  taken  away,  the 
edges  of  the  wound  are  to  be  brought  accu- 
rately together,  and  retained  in  contact  by 
strips  of  adhesive  plaster.  Sutures,  so  much 
employed  by  the  older  surgeons  are  now  justly 
laid  aside,  as  they  generally  retard  the  cure.  It 
is  not  only  necessary  to  keep  the  lips  of  the 
wound  in  contact,  the  skin  must  also  be  support- 
ed, in  connexion  with  the  parts  beneath,  by 
means  of  a compress,  retained  in  its  situation  by 
a proper  bandage. 

Tumours  beneath  the  fascia  are  more  frequent 
in  their  occurrence,  than  those  exterior  to  it,  and 
are  much  more  dangerous  in  their  nature.  Such 
tumours  are  firmly  bound  down  by  the  fascia, 
they  are  flattened  on  their  surface,  are  conse- 
quently large  before  they  protrude  externally, 
and  are  intimately  connected  with  the  deep 
seated  parts.  They  produce  greater  effect  on 
breathing  and  swallowing  than  would  be  expect- 
ed, from  their  apparently  small  size.  Indeed, 
the  extent  of  their  adhesions  can  hardly  be  dis- 
covered, because  although  they  be  small  and  re- 
gular on  their  outer  surface,  they  often  stretch 
back  amongst  the  muscles  and  vessels,  and  ad- 
here to  the  large  nerves.  Where,  therefore,  a 
tumour  is  deep-seated,  is  of  a specific  nature, 


48 


ON  THE  SURGICAL  ANATOMY 


and  is  evidently  on  the  increase,  there  can  be  no 
doubt,  that  if  other  circumstances  be  favourable, 
it  ought,  without  delay,  to  be  removed. 

In  the  neck,  even  simple  tumours  may  require 
extirpation,  because,  if  they  do  not  yield  to  me- 
dicine, but,  on  tbe  contrary,  continue  to  enlarge, 
they,  in  the  end,  come  to  compress  the  trachea 
and  oesophagus,  by  which,  ultimately,  they  will 
produce  as  much  mischief,  as  if  they  had  been 
of  a specific  nature.  About  the  throat  there 
are  many  muscles  which  leave  interstices  between 
themselves,  and  there  are  many  primary  branches 
of  vessels  and  nerves  interwoven  with  these  mus- 
cles, which  all  become  intimately  concerned  with 
tumours  here. 

From  the  resistance  afforded  by  the  platys- 
ma  myoides  and  the  fascia,  such  tumours  pe- 
netrate between  the  contiguous  muscles,  and 
encircle  the  subjacent  vessels  and  nerves,  ren- 
dering, where  the  disease  is  advanced,  the  ex- 
cision of  these  swellings  peculiarly  perplex- 
ing to  the  surgeon,  and  dangerous  to  the  pa- 
tient. Indeed,  there  are  many  tumours  formed 
in  the  region  between  the  chin  and  the  chest,  to 
attempt  the  removal  of  which  would,  on  the 
part  of  the  operator,  betray  the  grossest  igno- 
rance of  the  structure  of  the  neighbouring  parts. 
Some  tumours  are  so  deeply  attached  to  the 
pharynx,  are  so  intricately  entangled  among 
important  arteries  and  nerves,  and  so  firmly  fixed 


OF  THE  HEAD  AND  NECK. 


49 


to  the  muscles  in  the  vicinity,  that  to  undertake 
their  extirpation  would  be  to  form  the  resolution 
to  injure  all  these  parts. 

This  establishes  most  forcibly  the  propriety, 
nay,  it  proves  the  absolute  necessity,  of  as 
speedy  a removal  of  the  morbid  parts,  as  is 
compatible  with  prudent  attempts  to  remove  the 
tumour  without  operation.  If  distant  parts  have 
suffered  from  an  extension  of  the  morbid  action, 
no  one  can  be  certain  that  all  the  diseased  sub- 
stance has  been  cleared  away;  and  if  a single  atom 
of  the  contaminated  parts  be  permitted  to  remain, 
the  patient  is  in  a condition  equally  dangerous  as 
before  we  operated.  The  disease  is  suspended, 
not  eradicated,  and  the  secondary  affection  is 
worse  than  the  first. 

A useful  distinction  of  tumours  might  be  form- 
ed, were  we  a priori  able  to  determine  their 
structure,  by  dividing  them  into  such  as  depend 
merely  on  a preternatural  deposition  of  parti- 
cles, resembling  in  texture  the  original  structure 
of  the  part;  and  into  such  as  depend  on  an  in- 
crease of  size,  produced  by  a change  of  the  natu- 
ral organization.  It  will  be  found  that  the  first 
species  is  generally  indolent,  and  little  prone  to 
inflame  or  ulcerate,  except  when  teazed  and  irri- 
tated by  improper  treatment.  The  second  species 
from  the  very  nature  of  their  constituents,  are 
liable  to  inflame,  and  either  sphacelate,  fungate, 
or  ulcerate. 

7 


m 


ON  THE  SURGICAL  ANATOMY 


Mr.  John  Bell  maintains,  that,  originally,  every 
tumour  is  produced  by  an  excess  of  healthy  nutri- 
tion, and  he  would  persuade  us,  that  ultimately 
the  parts  are  modified  “in  form  and  character,  by 
many  changes  produced  by  occasional  inflamma- 
tion-or  ulceration.”  One  would  hardly  have  expec- 
ed  such  an  assertion  from  a surgeon,  who  would 
make  us  believe  that  he  had  traced  the  nature 
and  properties  of  these  morbid  productions  from 
their  simple  beginnings  to  their  final  termination. 
Shall  Mr.  Bell  convince  any  one,  that  in  cancer 
or  scrophula,  the  tumour  was,  in  the  first  instance 
formed  of  healthy  parts;  but  that,  eventually, 
the  swelling  obtained  the  peculiar  character  be- 
longing to  these  different  affections,  “by  occasion- 
al inflammation  or  ulceration?”  I should  be 
sorry  to  waste  time  in  animadverting  on  this  con- 
jecture, were  it  not  that,  to  me,  it  appears  a 
a point  highly  requisite  to  be  well  ascertained. 
It  must  be  the  regulator  of  our  practice.  If  pri- 
marily every  tumour  be  simple,  then  the  whole 
art  of  the  surgeon  must  consist  in  keeping  it  sim- 
ple. His  object  must  be  to  avoid  the  induction 
of  “occasional  inflammation  or  ulceration.” 

There  is  in  this  hypothesis  nothing  precise, 
and  nothing  really  useful;  but  if  admitted,  there 
is  much  positively  hurtful,  as  will  lead  to  a timid 
and  procrastinating  practice.  It  would,  therefore, 
lie  a most  desirable  object  with  the  surgeon  to 
become  acquainted  with  the  criteria,  by  which  he 


OF  THE  HEAD  AND  NECK. 


51 


would  be  enabled  to  distinguish  those  tumours 
which  were  of  a specific,  from  those  which  were 
of  a simple  nature.  Were  this  practicable,  he 
would  be  able,  in  almost  every  case,  to  cure  the 
patient;  for  in  the  incipient  stage,  few  tumours, 
in  comparison  of  the  many  which  occur,  are  so 
placed  as  to  prevent  his  extirpating  them.  But, 
as  in  the  present  state  of  our  knowledge,  we  have 
it  not  in  our  power  to  do  more  than  form  a rude 
notion  of  the  nature  of  swellings,  we  often  mis- 
take a specific  for  a simple  tumour,  and  waste 
time  in  useless  endeavours  to  promote  its  removal 
without  an  operation.  We,  in  fact,  allow  it  to 
acquire  such  a size,  and  to  form  such  connexions, 
that  when  we  become  convinced  of  its  intractable 
disposition,  it  is  no  longer  optional  with  us  to  take 
up  the  knife  with  any  reasonable  prospect  of 
success. 

With  more  zeal  than  success,  Mr.  Abernethy 
has  endeavoured  to  arrange  tumours  according  to 
their  textures,  but  his  plan  is  liable  to  this  great 
objection,  that  we  can,  for  the  most  part,  only 
discover  the  real  nature  of  the  parts  by  actual 
examination.  That  Mr.  Abernethy  has  failed  to 
communicate  criteria,  by  which  we  may  generally 
estimate  the  nature  of  tumours  in  the  living  pa- 
tient, is  indisputable;  yet,  let  it  not  be  imagined, 
that  I would  insinuate  that  this  is  to  be  imputed 
to  any  insufficiency  on  his  part  for  the  execution 
of  the  task  he  has  undertaken.  On  the  contrary. 


52 


ON  THE  SURGICAL  ANATOMY 


all  must  allow,  that  the  facts,  as  yet  collected,  re- 
specting tumours,  are  too  limited,  and  our  in- 
formation respecting  morbid  structure,  is  too 
vague,  to  enable  any  one  to  form,  on  a solid  basis, 
a classification  of  tumours  which  shall  be  emi- 
nently useful  to  the  practical  surgeon.  It  is 
well  known,  that  tumours  essentially  different 
in  their  nature,  present  externally  similar  fea- 
tures, which  renders  futile  any  attempt  to  classify 
such  morbid  productions. 

After  these  remarks,  it  would  be  folly  in  me 
to  offer  any  other  than  a few  very  general  obser- 
vations on  tumours,  reserving  the  considerations 
regarding  the  extirpation  of  these,  till  after  I 
shall  have  pointed  out  the  relation  of  parts  about 
the  neck,  and  attended  to  the  local  connexions 
of  the  numerous  variety  of  tumours  which  form 
in  the  region  of  the  throat. 

From  the  high  importance  of  the  vessels  and 
nerves  about  the  neck,  it  becomes  the  duty  of 
the  surgeon,  in  every  morbid  condition  of  these 
parts  to  inquire  into  the  cause  of  the  disease, 
to  ascertain  carefully,  whether  it  be  a primary, 
or  a secondary  affection;  and  if  secondary,  whe- 
ther it  be  sympathetic,  or  dependent  on  absorp- 
tion of  a specific  morbid  poison.  If  it  be  clear- 
ly ascertained  to  be  a primary  affection,  then  it 
is  necessary  to  investigate  the  origin,  the  pro- 
gress, and  the  existing  state  of  the  tumour,  to  en- 
able us  to  decide  justly,  as  to  the  propriety  of 


OF  THE  HEAD  AND  NECK. 


53 


allowing  it  to  remain,  or  to  determine  on  its  im- 
mediate extirpation. 

It  is  not  in  primary  affections  alone,  that  the 
surgeon  is  sedulously  to  trace  the  progress  of  the 
disease;  he  is  called  on  to  be  equally  careful  to 
make  himself  acquainted  with  the  causes  of  se- 
condary tumours.  But  here  it  is  to  be  remem- 
bered, that  the  field  is  less  extended;  if  the  pri- 
mary disease  be  simple,  the  secondary  must  be 
so  also,  and  vice  versa,  where  the  latter  swelling 
is  dependent  on  absorption.  Where,  however, 
the  primary  tumour  has  not  proceeded  to  ulcera- 
tion, we  may  hesitate  regarding  the  nature  of  the 
secondary;  we  may  suspect  that  it  is  merely  sym- 
pathetic. 

Facts  connected  with  the  history  of  tumours, 
render  it  probable  that  the  lymphatic  glands 
never  do  become  specifically  contaminated  pre- 
vious to  the  formation  of  an  ulcer,  or  a fungus  in 
the  part  primarily  affected;  but  earlier  than  this, 
we  know  that  they  often  swell  from  sympathetic 
connexion  with  the  morbid  parts.  This  we  some- 
times see  exemplified  in  carcinoma  of  the  breast, 
accompanied  with  enlargement  of  the  axillary 
glands.  These  tumours  occasionally  disappear 
after  the  removal  of  the  mamma,  which  clearly 
shews,  that  they  were  not  dependent  on  specific 
contamination. 

Although  I have  stated  that  it  is  probable 
that  the  absorbent  glands  are  never  specifically 


54 


ON  THE  SURGICAL  ANATOMY 


contaminated,  till  the  primary  disease  has  pro- 
ceeded to  ulceration,  or  to  the  formation  of  the 
fungus,  yet  I am  not  ignoran-,  that  some  are  of  a 
different  opinion.  It  has,  indeed,  been  conjec- 
tured, that  there  may  be  specific  irritation,  as 
well  as  specific  absorption,  but  this  is  a doctrine 
which  ought  not  to  be  admitted,  without  complete 
proof  of  its  accuracy;  a proof,  which  on  this  point 
is  still  a desideratum. 

As  I would  wish  to  be  perfectly  understood  on 
this  subject,  I may  mention,  that  we  are  by  no 
means  to  infer,  that  a secondary  tumour  is  sympa- 
thetic, merely  because  the  primary  one  has  not 
ulcerated  externally;  this  is  really  no  proof.  Af- 
ter the  removal  of  the  latter,  we  are  carefully  to 
examine,  whether  there  be  any  fungi,  or  ulcera- 
ted points  in  its  centre.  If  these  existed,  I 
would  incline  to  the  belief  that  the  secondary  tu- 
mour was  specific,  and  would,  therefore,  without 
hesitation  advise  its  removal;  but  if  after  a minute 
inspection  of  the  primary  tumour  no  traces  of 
fungi  or  ulceration  could  be  perceived,  I do  not 
know  how  far  it  would  be  advisable  to  extirpate 
the  secondary.* 

* The  editor’s  observation  on  the  subject  of  tumours,  which  has  been 
considerable,  lead  him  to  differ  from  the  opinion  expressed  by  Mr.  Burns, 
as  to  its  being  necessary  that  ulceration  or  fungus  shall  have  taken  place  in 
the  primary  affection,  before  the  secondary  one  can  become  specifically  con- 
taminated. In  many  instances  w here  the  most  accurate  and  minute  dissection 
has  been  unable  to  detect  in  the  original  tumours  either  incipient  ulcera- 
tion or  fungus,  the  structures  of  those  which  have  arisen  secondarily  have 
been  -found  to  present  tire  same  characters  of  their  being  of  a specific  n»- 


OF  THE  HEAD  AND  NECK. 


55 


Our  great  object,  therefore,  and  our  chief  in- 
ducement to  distinguish  those  tumours  about  the 
neck,  which  originate  from  simple  irritation,  from 
those  which  are  dependent  on  specific  contamina- 
tion, is  with  a view  to  regulate  our  proceedings. 
If  we  incontrovertibly  ascertained,  that  the  tu- 
mour was  of  a specific  nature,  we  would,  without 
delay,  extirpate  the  diseased  parts.  Where,  how- 
ever, we  were  uncertain,  we  would  be  less  deci- 
ded in  our  conduct.  In  doubtful  cases,  there  is 
an  obvious  motive  for  delay.  While  there  is  a 
probability  that  the  tumour  is  simple,  we  may 
succeed  in  removing  it  without  an  operation;  but, 
in  specific  tumours  we  have  no  such  inducement, 
procrastination  will  only  permit  the  disease  to 
gain  ground. 

These  general  observations  shew,  that  there 
is  much  uncertainty  in  the  diagnosis  of  tu- 
mours about  the  neck;  some  being  produced  by 
simple  irritation,  which,  to  one  who  satisfied  him- 
self with  a superficial  inquiry  into  the  case,  would 
seem  to  be  induced  by  the  absorption  of  specific 
virus,  while  others  really  of  a specific  nature, 
are,  from  the  indolence  of  their  actions,  supposed 
to  be  simple;  and  under  this  impression,  are 

ture,  as  those  exhibited  in  the  primary  affections.  The  rule  of  practice 
which  his  experience  would  induce  him  to  inculcate,  would  be,  in  every 
case,  before  performing  an  operation  for  the  removal  of  a tumour  supposed 
to  be  of  a specific  character,  to  examine  carefully  those  glands,  which  re- 
ceive their  lymphatics  from  that  situation,  and  should  any  of  them  be  found 
enlarged,  to  remove  them  at  the  same  time  that  we  extirpate  the  primary 
tumour. — Ed. 


56 


ON  THE  SURGICAL  ANATOMY 


allowed  to  remain  and  extend  their  connexions, 
til!  they  get  beyond  the  reach  of  surgery.  This 
want  of  well  defined  character  in  the  early  stage 
of  the  disease,  is  a source  of  great  ambiguity.  I 
have  thus  known  a small  tumour  of  the  spongoid 
species,  which,  when  the  patient  first  applied  for 
assistance,  could  have  been  easily  and  safely 
extirpated,  left  for  months,  gaining  ground  daily, 
plunging  deeper  and  deeper,  becoming  more  and 
more  intricately  attached  to  the  parts  in  the  vici- 
nity, during  all  which  time  the  woman  was  teazed 
with  burnt  sponge,  muriate  of  lime,  and  repeated 
blisters;  remedies  which  are  well  known  to  have 
no  control  over  that  disease. 

At  last,  when  the  character  of  the  complaint 
became  so  decided,  that  no  one  could  mistake 
it,  the  surgeon  consoled  himself,  that  now  the 
tumour  had  extended  too  far  to  permit  of  ex- 
tirpation; that  to  attempt  this,  would  be  to  form 
the  resolution  to  destroy  the  patient.  This  is, 
however,  at  all  times  a poor  excuse,  especially 
when  the  practitioner  is  conscious  that  the  ma- 
lignancy of  the  disease  depended,  in  a great  mea- 
sure, on  his  own  procrastination  and  want  of 
knowledge. 

Tumours  in  any  part  of  the  body,  are  of  a 
nature  to  require  the  most  prompt  and  decided 
practice,  but  our  vigilance  must  be  doubled, 
when  the  morbid  parts  are  seated  in  the  vicinity 
of  large  vessels  and  important  nerves.  I have 


OF  THE  HEAD  AND  NECK. 


57 


known  one  surgeon,  after  much  unnecessary  de- 
lay, undertake  to  renove  a tumour  from  the 
neck,  but  I may  safely  venture  to  affirm,  that  the 
same  gentleman  will  be  in  no  hurry  to  begin  a 
similar  operation. 

When  the  tumour  is  decidedly  of  a simple  na- 
ture, the  object  of  the  surgeon  plainly  is,  to  pro- 
mote the  absorption  of  the  newly  formed  parts; 
but  where  he  fails  to  accomplish  this,  he  next 
attempts  to  induce  suppuration  In  primary  tu- 
mours, however,  as  it  is  often  difficult  to  disco- 
ver the  real  nature  of  the  disease,  we  necessarily 
act  on  an  uncertainty.  Yet,  in  all  doubtful  cases, 
I think  we  are  authorised  to  use  means  to  pro- 
cure absorption  of  the  morbid  parts;  but  it  is  by  no 
means  so  clear,  that  in  such  cases,  we  are,  after 
these  have  failed,  to  delay  endeavouring  to  in- 
duce suppuration,  since  this  event  would  only 
be  useful  in  tumours  of  such  a nature,  as  not  to 
require  extirpation,  unless  from  their  mechanical 
effect  on  some  neighbouring  and  highly  important 
part.  In  simple  swelling,  we  are,  however,  to 
the  latest,  to  continue  our  endeavours  to  promote 
absorption,  or  to  procure  suppuration;  for  if  we 
can  succeed  in  effecting  this,  all  danger  is  compa- 
ratively at  an  end.  The  patient,  when  the  ab- 
scess bursts,  or  is  opened,  is  placed  beyond  the 
reach  of  immediate  risk,  and  time  is  afforded  to 
the  surgeon  to  suit  his  plans  to  the  nature  of  the 
case. 


8 


58 


ON  THE  SURGICAL  ANATOMY 


After  the  description  of  the  fascia,  and  the  ge- 
neral remarks  on  the  modification  of  the  charac- 
ters of  tumours  by  that  sheath,  it  will  be  neces- 
sary to  attend  to  the  anatomy  of  the  lower  and 
lateral  part  of  the  neck.  We  must  trace  the  con- 
nexions of  the  subclavian  arteries  at  the  root  of 
the  neck. 

From  their  origin,  these  arteries  mount  up- 
ward, and  incline  outward,  and  are  covered,  till 
they  reach  the  scaleni  muscles,  by  the  sterno- 
mastoid  muscles.  Between  the  aorta  and  scaleni 
muscles,  the  subclavian  artery  is  connected 
with  several  important  vessels  and  nerves.  It 
is  in  the  vicinity  of  the  nervus  vagus,  of  the 
recurrent  laryngeal  nerve,  of  the  sympathetic 
nerve,  of  the  phrenic  nerve,  and  the  subclavian 
vein;  and  on  the  left  side  it  is  intimately  con- 
nected with  the  termination  of  the  thoracic 
duct.  These  parts  are  all  grouped  together 
in  a very  narrow  space,  and  the  perplexity  of 
their  dissection  is  further  increased  by  the  in- 
terlacement of  the  different  nerves  with  one 
another. 

The  natural  connexion  of  these  parts  are  best 
shown  by  merely  raising  the  sternal  extremity  of 
the  sterno-mastoid  muscle.  If  this  be  done,  the 
nervus  vagus  will  be  brought  into  view,  lying  on 
the  fore  part  of  the  subclavian  artery,  almost 
directly  behind  the  sternal  end  of  the  clavicle: 
and  exactly  opposite  to  the  nervous  vagus,  but 


OF  THE  HEAD  AND  NECK. 


59 


behind  the  artery,  the  lower  cervical  ganglion  of 
the  sympathetic  nerve  will  be  brought  into  view. 
The  recurrent  nerve  on  the  right  side,  hooks 
round  the  subclavian  artery,  and  in  its  course 
towards  the  larynx,  ascends  along  the  tracheal  side 
of  the  sympathetic  nerve.  On  the  left  side  it 
twines  round  the  arch  of  the  aorta,  and  in  mount- 
ing upward,  is  interposed  between  the  subcla- 
vian artery,  and  the  oesophagus.  The  subclavian 
vein  lies  anterior  to  the  artery,  and  in  the  col- 
lapsed state,  sinks  nearer  to  the  thorax. 

This  is  its  usual  position  in  the  dead  body,  but 
in  the  living  person  its  relation  to  the  artery  is 
constantly  changing.  Alternately  it  is  flaccid 
and  full;  in  the  first  state  it  bears  the  same  rela- 
tion to  the  artery,  as  in  the  dead  subject;  under 
the  latter  circumstances  it  swells  out  quite  tense, 
and  ascends,  so  as  in  some  measure,  to  overhang 
and  conceal  the  artery.  The  thoracic  duct  en- 
ters the  left  subclavian  vein  about  an  eighth  of  an 
inch  nearer  to  the  acromion,  than  the  point  where 
the  internal  jugular  vein  empties  itself  into  the 
subclavian  vein.  The  termination  of  the  tho- 
racic duct  is  situated  between  the  sternal  and 
clavicular  portions  of  the  sterno-mastoid  muscle. 

I have  been  thus  particular  in  the  description 
of  the  parts  connected  with  the  subclavian  artery, 
between  its  origin  and  the  scaleni  muscles;  be- 
cause, one  who  knows  their  position,  and  is  aware 
of  their  importance,  will  correctly  estimate  the 


60 


ON  THE  SURGICAL  ANATOMY 


risk  of  attempting  to  tie  the  artery  nearer  to 
the  heart  than  the  scaleni  muscles  It  will  also 
impress  on  the  mind  of  the  surgeon,  the  great 
danger  of  extirpating  tumours  from  behind  the 
root  of  the  sterno-mastoid  muscle.  Our  ances- 
tors, who  were  very  deficient  in  anatomical  know- 
ledge, had  the  sense  and  modesty  to  decline  any 
very  hazardous  operation.  In  the  present  age, 
timidity  forms  no  part  of  the  character  of  the  ge- 
nerality of  surgeons.  But  in  operating,  some- 
thing more  than  boldness  is  required;  knowledge, 
prudence,  and  caution,  are  requisite. 

In  tying  the  subclavian  artery  nearer  to  the 
heart  than  the  scaleni  muscles,  there  is  not 
only  considerable  risk  on  account  of  its  connex- 
ions, but  there  is  even  much  danger  to  be  ap- 
prehended from  confounding  aortic  aneurism,  with 
aneurism  of  the  subclavian  artery.  It  would  be 
doing  injustice  to  Mr.  Astley  Cooper,  were  I to 
omit  mentioning,  that  to  him  1 was  first  indebted 
for  the  communication  of  this  fact,  which  I had 
lately  an  opportunity  of  seeing  verified  in  a most 
striking  and  highly  interesting  case, — a case  on 
which  several  of  the  most  distinguished  practi- 
tioners in  Edinburgh,  and  almost  every  surgeon 
in  Glasgow,  were  consulted. 

The  nature  of  the  disease  appeared  to  be  so  de- 
cided, and  its  situation  in  the  subclavian  artery  so 
clear,  that  on  that  subject  there  was  no  difference 
of  opinion.  Some  were,  however,  of  opinion,  that 


61 


OF  THE  HEAD  AND  NECK. 

an  operation  might  be  performed,  while  others 
were  fully  convinced  that  the  case  was  hopeless. 
For  myself,  I must  confess,  that  I was  firmly  per- 
suaded, that  in  the  early  stage  of  the  disease,  an 
operation  might  have  been  beneficial:  those  who 
dissented,  did  it  on  the  belief  that  the  aneurism 
was  seated  so  near  to  the  origin  of  the  subcla- 
vian artery,  that  to  get  beyond  the  limits  of  the 
disease,  the  ligature  must  have  been  passed 
round  the  arteria  innominata  itself, — an  opera- 
tion, said  they,  for  which  there  was  no  prece- 
dent, and  which  there  was  much  reason  to  sup- 
pose would  fail.  Those  who  approved  of  it,  did 
so,  on  the  ground  that  death  was  inevitable,  if 
the  disease  was  left  to  run  its  course;  that  if  an 
operation  was  performed,  the  most  which  was 
ever  expected  was,  that  by  cutting  off  the  direct 
current  of  blood  through  the  sac,  coagulation  of 
its  contents  might  take  place.  To  the  occurrence 
of  this  event,  and  of  this  event  alone,  a favour- 
able issue,  if  it  did  take  place,  must  have  been 
attributed. 

The  great  objection  which  we  had  to  the  expe- 
riment, was  the  uncertainty  with  respect  to  the 
state  of  the  coats  of  the  arteria  innominata;  we 
entertained  no  dread  of  the  circulation  being 
supported  in  the  right  arm,  nay,  we  reduced  it 
to  a demonstration.  On  the  dead  subject,  I tied 
the  arteria  innominata  with  two  ligatures,  and 
cut  across  the  vessel  in  the  space  between  them, 


62  ON  THE  SURGICAL  ANATOMY 

without  hurting  any  of  the  surrounding  vessels. 
Afterwards,  even  coarse  injection  impelled  into 
the  aorta,  passed  freely  by  the  anastomosing 
branches  into  the  arteries  of  the  right  arm, 
filling  them  and  all  the  vessels  of  the  head 
completely. 

After  these  remarks,  I shall,  without  alteration, 
transcribe  the  history  and  progress  of  the  disease 
from  my  case  book: — “On  Friday  the  13th  of 
October,  1809,  I was  requested  to  visit  an  officer 
belonging  to  one  of  the  regiments  in  town.  He 
had  risen  from  the  ranks,  and  had,  till  about  that 
time,  been  an  able,  active,  and  useful  soldier.  He 
had  been  engaged  in  very  laborious  service  in 
India,  and  while  in  that  country,  he  had  been 
confined  by  an  affection  of  the  liver,  which  had 
produced  a depression  of  his  spirits,  from  which 
he  had  not  fully  recovered  at  the  time  I saw  him. 
When  I visited  him  he  was  ailing,  but  felt  diffi- 
culty in  defining  his  complaints, — he  told  rather 
what  he  had  not,  than  what  he  actually  had.  A 
few’  weeks  ago,  he  supposed  that  his  left  arm  felt 
benumbed,  and  nearly  about  the  same  time,  he 
experienced  some  unpleasant  sensations  about  his 
head. 

“Till  Sunday  last,  however,  he  was  not  sup- 
posed to  be  seriously  unwell.  On  the  afternoon  of 
that  day,  while  travelling  at  an  easy  rate  in  a post- 
chaise,  he  was  suddenly  seized  with  a very  acute 
pain  over  the  uppermost  rib,  on  the  right  side, — 


OF  THE  HEAD  AND  NECK. 


63 


a pain  which  extended  even  to  the  top  of  the  shoul- 
der. This  pain  was  so  much  increased  by  the  motion 
of  the  carriage,  that  he  was  compelled  to  quit  it, 
and  finish  his  journey  on  foot.  He  walked  about 
two  miles.  On  his  arrival  in  town,  he  was  led  to 
examine  the  pained  part,  where  he  discovered  for 
the  first  time,  a firm  pulsating  tumour,  which 
alarmed  him  very  much.  When  I saw  him,  which 
was  at  the  request  of  the  practitioner  who  had 
already  visited  him,  he  had  an  anxious,  though 
by  no  means  an  unhealthy  look.  He  complained 
of  little  present  inconvenience  from  his  complaint, 
except  pain,  stretching  from  the  root  of  the  neck 
towards  the  back;  but  he  dreaded  the  result  of 
his  disease,  the  nature  of  which  he  had  disco- 
vered. 

“A  tumour  about  the  size  of  a pigeon’s  egg 
was  situated  just  behind  the  clavicle,  and  on  the 
acromial  edge  of  the  sterno-mastoid  muscle.  It 
pulsated  strongly,  while  the  radial  artery  of  the 
right  arm  acted  with  little  vigour;  but  on  compa- 
rison with  the  artery  of  the  opposite  arm,  the 
pulse  was  stronger.  In  both  arms  the  pulse  was 
regular,  when  I examined  it,  but  during  the  two 
preceding  days,  I was  informed  that  it  had  been 
intermittent.  In  regard  to  the  tumour  itself,  it 
was  placed  in  part  beneath  the  clavicular  portion 
of  the  sterno-mastoid  muscle,  but  the  greatest 
part  of  it  lay  nearer  to  the  acromion  than  the 
muscle.  By  pressure  the  tumour  could  be  nearly 


64 


OjST  THE  SURGICAL  ANATOMY 


emptied,  but  while  doing  this  he  complained,  of 
considerable  uneasiness.  So  soon  as  the  pres- 
sure was  removed,  the  sac  became  again  distend- 
ed, and  the  blood  in  entering  it  communicated  a 
whizzing  sensation  to  the  finger.  The  impulse 
was  at  the  same  time  great,  and  on  the  contrac- 
tion of  the  ventricle,  the  sac  became  exceedingly 
tense,  and  the  throbbing,  and  whirlpool-like  mo- 
tion of  its  contents,  were  conspicuous  features  of 
the  disease.  The  arteria  innominata  was  felt 
beating  at  the  top  of  the  sternum,  apparently  in 
no  degree  enlarged.  The  common  carotid  acted 
more  feebly  than  on  the  opposite  side.  The  skin 
was  free  from  discoloration,  and  his  rest  was  un- 
broken. 

“On  reviewing  this  case,  we  had  no  doubt  as 
to  the  nature  of  the  disease,  indeed  its  character 
was  too  decided  to  be  mistaken.  We  earnestly 
wished  to  be  of  use  to  him,  and  he  declared  his 
readiness  to  submit  to  any  operation.  Yet  who 
could  urge  an  operation  in  such  a case? — What 
certainty  was  there  that  the  coats  of  the  arteria 
innominata  were  not  diseased,  even  to  where  that 
vessel  arises  from  the  aorta?  The  immediate  risk 
of  operation  would  have  been  immense,  it  would 
probably  have  accelerated  the  fatal  issue,  which 
he  was  directed  to  retard  by  low  diet,  by  ab- 
stinence from  wine,  spirits,  or  fermented  liquors, 
by  keeping  tbe  bowels  most  easy,  by  avoiding 
either  corporeal  exertion,  or  mental  irritation, 


OF  THE  HEAD  AND  NECK.  65 

and  by  employing  digitalis  to  moderate  vascular 
action. 

“I  had  occasional  opportunities  of  seeing  the 
patient,  but,  till  toward  the  end  of  December, 
there  was  little. change  on  either  the  tumour  or 
general  health,  if  we  except  a tendency  to  oedema 
and  depression  of  the  spirits.  The  former  was 
completely  removed  by  the  use  of  digitalis.  On 
the  38th  December,  I found  the  tumour  much 
flattened,  and  could  perceive  very  little  pulsation 
about  the  arteria  innominata.  Along  the  subcla- 
vian, vertebral,  and  common  carotid  arteries, 
there  was  a peculiar  thrilling  sensation  during 
their  action.  He  has  now  frequent  paroxysms  of 
pain,  extending  along  the  right  side  of  the  head, 
and  complains  of  constant  numbness  of  the  left 
arm. 

“The  food  he  takes  is  light,  his  bowels  are 
easy,  but  he  is  weaker  and  more  anxious  than 
before.  The  pulse  is  nearly  similar  at  both 
wrists.  On  one  occasion,  he  lately  felt  a sudden 
rushing  of  blood  to  his  head,  followed  for  a short 
time,  by  dimness  of  vision. 

“January  27th,  1810. — The  tumour  is  no  lar- 
ger, but  it  is  flatter,  broader,  and  fully  more 
incompressible.  It  now  extends  to  the  very 
tracheal  edge  or  the  sterno-mastoid  muscle,  but 
appears,  as  yet,  to  make  no  pressure  on  the  as- 
pera  arteria.  When  the  sac  is  squeezed,  he  com- 
plains of  a sharp  pain  extending  round  the  shoul- 
9 


66 


ON  THE  SURGICAL  ANATOMY 


der.  The  jarring  action  of  the  subclavian  and 
carotid  arteries  is  not  so  well  marked  as  before. 
The  pulse  in  the  right  arm  is  sunk  and  feeble, 
the  numbness  of  the  left  is  less,  but  the  right  hand 
has  of  late  become  slightly  cedematous.  He  has 
coldness  of  the  feet,  vertigo,  and  feeling  of  blood 
at  times  rushing  into  his  head.  His  general  ap- 
pearance is  somewhat  improved,  but  his  spirits 
are  very  much  depressed, — he  is  weak,  and  feels 
fully  persuaded,  from  his  sensations,  that  the 
disease  is  extending  into  the  chest.  One  of  the 
perforating  arteries,  from  the  internal  mammary 
vessel  is  distinctly  felt  enlarged. 

“March  23d. — Till  yesterday  there  was  very 
little  alteration  in  the  size  of  the  tumour,  and 
almost  no  change  in  the  constitutional  symptoms. 
The  right  arm  had  slowly  lost  its  power,  the  hand 
remained  permanently  of  a purplish  colour,  and 
was  sometimes  cedematous.  When  he  walked  the 
swelling  became  tense,  and  by  its  distension  pro- 
duced pressure  on  the  veins,  returning  the  blood 
from  the  head,  occasioning  vertigo,  failure  of 
sight,  and  turgescence  of  the  veins  of  the  head 
and  neck, — symptoms  which  soon  abated  after 
desisting  from  exercise.” 

“Yesterday,  a short  time  after  dinner,  which 
consisted  merely  of  bread  and  water,  the  tumour 
suddenly  became  greatly  increased  in  size — not 
only  projecting  farther  out,  but  extending  late- 
rally in  every  direction,  except  towards  the  tra- 

» 


OF  THE  HEAD  AND  NECK. 


67 


ehea.  The  clavicle  appears  to  be  forced  away 
from  the  sternum,  and  pungent  pain  is  occasion- 
ed by  even  gentle  pressure  on  either  the  tumour 
or  right  side  of  the  neck.  But  it  is  rather  cu- 
rious, that  he  felt  little  pain  during  the  sudden 
enlargement  of  the  sac, — he  had,  at  that  time, 
rather  the  sensation  of  something  giving  way  or 
yielding.  The  integuments  covering  the  sac  are 
now  slightly  discoloured,  and  obscure  pulsation 
can  be  discovered  in  the  upper  part  of  the  right 
side  of  the  chest.  The  pulse  in  the  right  arm  is 
rather  more  distinct,  yet  it  is  less  so  than  in  the 
opposite  arm.  He  has  no  actual  difficulty  in 
breathing,  but  he  says  that  he  is  short  winded. 
The  rest  which  he  procures,  is  obtained  by  the 
employment  of  the  ext.  of  hyoscyamus,  and  his 
bowels  are  kept  regular  by  the  daily  use  of 
stewed  fruits. 

“March  31st. — The  tumour  has  increased  con- 
siderably in  size,  and  for  several  days  past,  his 
voice  has  been  gradually  impaired,  and  is  now  so 
much  injured,  that  he  can  only  converse  in  a low 
under  tone,  hardly  audible.  The  sternal  extre- 
mity of  the  clavicle  seems  partly  absorbed. 

“April  15th. — The  tumour  has  considerably 
increased  in  size,  and  has  extended  toward  the 
left  side,  but  although  it  overhangs  the  trachea, 
he  does  not  experience  much  difficulty  in  breath- 
ing; he  complains,  however,  of  some  uneasiness 
when  swallowing,  and  his  voice  is  still  weak  and 


68 


ON  THE  SURGICAL  ANATOMY 


raucous.  He  is  disturbed  with  painful  sensa- 
tions about  the  left  shoulder,  similar  to  those 
he  felt  in  the  right  about  the  commencement  of 
the  disease,  and  he  is  frequently  distressed  with 
palpitation,  and  feeling  of  failure  about  the  re- 
gion of  the  heart,  accompanied  with  a tendency 
to  syncope.  His  feet  are  still  unusually  cold, 
even  when  the  rest  of  his  body  is  warm.  At  one 
point  the  tumour  is  thin,  projects  into  a small 
papilla,  seated  just  on  the  acromial  side  of  the 
sterno-mastoid  muscle,  and  covered  with  delicate 
but  not  diseased  skin.  In  other  respects,  he  is 
much  the  same  as  formerly. 

“October  10th. — I was  requested  to-day  to 
visit  the  patient.  His  appearance  and  conversa- 
tion were  so  much  altered,  that  he  hardly  re- 
sembled himself;  his  face  was  cedematous,  and 
streaked  with  purple  veins;  his  right  hand  and 
arm  were  cold,  lumpish,  and  anasarcous,  and  the 
cellular  membrane  of  the  lower  extremities  was 
loaded  with  water.  He  moved  slowly,  and 
held  his  head  inclined  forward.  He  spoke  in  a 
short  and  hurried  whisper,  interrupted  every  few 
minutes  by  a hollow  cough,  and  profuse  expecto- 
ration of  greenish  yellow  matter.  He  had  no 
pain;  difficulty  in  breathing  and  want  of  sleep 
were  his  chief  complaints.  The  aneurism  was  in 
no  degree  enlarged  outwardly,  the  papilla- like 
projection  had  even  disappeared,  and  its  cover- 
ings were  now  much  thickened:  yet  it  caused 


OF  THE  HEAD  AND  NECK. 


69 


more  pressure  on  the  trachea,  and  from  the  very 
evident  tremulous  motion  which  I could  perceive 
in  the  upper  and  right  side  of  the  thorax,  I 
could  not  doubt  the  extension  of  the  disease 
into  the  chest.  The  disease  was  now  drawing  to 
a conclusion;  it  neither  admitted  of  alleviation, 
nor  of  being  cured,  and  of  this  the  patient  was 
fully  aware.  He  was  not,  therefore,  disappoint- 
ed, when  I informed  him  that  I had  no  remedy  to 
propose.  I left  him  with  directions  to  send  for 
me  if  he  became  worse. 

“In  four  days  we  were  called  to  inspect  his 
body.  The  dissection,  which  was  carefully  per- 
formed, proved  highly  interesting.  Appearances 
were  presented,  which,  a jpriovi,  no  one  expect- 
ed; the  vessel  which  was  supposed  to  have  been 
most  materially  affected,  was  found  perfectly 
healthy.  The  aneurism  arose  from  the  aorta, 
and  included  a considerable  part  of  the  arteria 
innominata.  The  right  subclavian  artery  was 
only  slightly  dilated  at  its  root;  along  its  course,  it 
was  rather  reduced  in  size.  The  tumour  mount- 
ed from  the  aorta,  considerably  above  the  ster- 
num, pressing  in  its  ascent,  the  descending  vena 
cava  to  the  right,  and  the  trachea  to  the  left;  ob- 
structing thus  the  breathing,  and  intercepting  the 
return  of  the  venous  blood  from  the  head  and 
arms.  It  also  pressed  the  root  of  the  right  sub- 
clavian artery  and  the  carotid  against  the  spine, 
retarding  in  this  way,  the  circulation  along  these 


70 


ON  THE  SURGICAL  ANATOMY 


vessels.  The  trachea  is  so  much  displaced,  that 
the  left  carotid  slants  across  its  front  to  reach  the 
side  of  the  neck.  The  right  side  of  the  heart  is 
little  affected;  the  left  ventricle  is  much  thickened, 
and  the  aortic  valves  are  in  part  ossified,  which, 
together  with  the  obstruction  to  the  circulation 
arising  from  the  pressure  of  the  tumour  on  the 
right  carotid  and  subclavian  arteries,  will  ex- 
plain the  increased  strength  of  the  muscular 
fibres  of  the  ventricle.  Just  above  the  heart, 
the  aorta  is  somewhat  dilated;  I say  dilated,  be- 
cause its  coats  are  healthy,  and  its  canal  free 
from  lymphatic  incrustation.  This  swelling  termi- 
nates below  the  commencement  of  the  arch.  The 
inner  surface  of  the  aneurismal  sac,  was  coated 
over  with  many  layers  of  organized  lymph,  which 
coating  was  especially  thick  and  strong  about  the 
highest  part  of  the  sac.  The  left  part  of  the 
arch  is  of  natural  size,  but  a little  below  the  com- 
mencement of  the  descending  aorta,  the  vessel  is 
again  dilated  into  a small  pouch.  The  oesopha- 
phagus  is  pushed  completely  from  behind  the 
trachea.” 

The  importance  of  this  case,  is  the  only  apo- 
logy I have  to  offer  for  its  great  length.  It 
elearly  and  satisfactorily  demonstrates,  how  se- 
rious the  consequences  would  have  been,  had  an 
operation  been  undertaken.  It  corroborates  Mr. 
Astley  Cooper’s  remark,  that  aneurism  of  the 
aorta  may  assume  the  appearance  of  being  seated 


Flat,  M 


JlTumxrtJ  /»'  .r  L 


OF  THE  HEAD  AND  NECK.  71 

in  one  of  the  arteries  of  the  neck;  an  inference 
drawn  from- the  examination  of  a case  which  came 
under  his  own  observation,  and  of  which  he  had 
the  goodness  to  transmit  a short  history  to  me 
along  with  a sketch,  illustrative  of  the  position  of 
the  tumour.  In  our  case,  the  aneurism  was  at- 
tached to  the  right  side  of  the  aortic  arch,  and 
involved  a part  of  the  arteria  innominata;  in  Mr. 
Cooper’s,  the  tumour  arose  from  the  left  side  of 
the  arch,  from  between  the  roots  of  the  left  sub- 
clavian and  carotid  arteries.  It  formed  a Flo- 
rence-flask-like cyst,  the  bulbous  end  of  which, 
projected  at  the  root  of  the  neck,  from  behind  the 
sternum,  and  so  nearly  resembled  aneurism  of  the 
root  of  the  carotid  artery,  that  the  practitioner 
who  consulted  Mr.  Cooper,  actually  mistook  the 
disease  for  earotid  aneurism.* 


DESCRIPTION  OF  THE  PLATES  OF  THESE  CASES. 

PLATE  I.  contains  an  anterior  view  of  the  aneurism  de- 
scribed in  page  62,  et  seq. 

A A,  the  right  and  left  ventricles  of  the  heart. — B.  the 
pulmonary  artery.' — C,  the  aorta,  which  is  considerably 
dilated  just  above  its  origin. — D,  the  arch  contracted  to  its 
proper  size. — E,  the  aneurismal  tumour  involving  the  root 
of  the  arteria  innominata.  mounting  up  behind. — F,  the 
sternum,  displacing  G,  the  clavicle,  the  sternal  extremity 


* See  Appeudix,  (A.) 


72 


ON  THE  SURGICAL  ANATOMY 


of  which,  is  sunk  into  the  coats  of  the  sac,  and  roughened 
bj  partial  absorption  of  its  substance.  Almost  the  whole 
of  the  cyst  which  projected  above  the  sternum  was  filled, 
and  rendered  solid  by  different  strata  of  buff-coloured  in- 
crustation. Toward  the  aorta,  the  lymphatic  exudation 
was  less  copious,  and  more  intermixed  with  coagulated 
blood. — H,  the  trachea  pushed  toward  the  left  side,  inso- 
much, that  I,  the  left  carotid  artery,  crosses  it  in  a slanting 
course  to  reach  the  side  of  the  neck. — The  trachea  is  not 
only  displaced;  it  is  likewise  reduced  by  the  pressure  of 
the  tumour  in  its  lateral  diameter,  and  increased  in  itsan- 
tero  posterior,  and  K,  the  oesophagus,  is  forced  completely 
from  behind  the  windpipe. — L,  denotes  the  little  saculated 
dilatation  of  the  descending  aorta. 

Had  the  tumour  in  its  commencement,  occupied  the  same 
situation  which  it  did  in  the  last  stage  of  life,  there  would 
have  been  no  hesitation  in  referring  the  disease  to  the  ar- 
teria  innominata.  But  it  is  to  be  carefully  remembered, 
that  in  this  very  patient,  the  first  appearance  of  the  sac  was 
nearer  to  the  acromion  than  the  sterno-mastoid  muscle;  at 
a point  where  no  one  would  expect  a tumour  to  present, 
which  had  worked  its  way  from  within  the  chest.  The 
gradual  progress  of  the  tumour,  first  toward  the  trachea, 
and  then  apparently  into  the  thorax,  tended  still  more  to 
mislead,  as  to  the  real  nature  of  the  complaint.  There 
was  no  wonder,  therefore,  that  we  should  have  been  led  to 
the  belief,  when  we  were  first  consulted,  that  the  disease 
was  seated  nearer  to  the  scaleni  muscles,  than  the  origin  of 
the  subclavian  artery,  and  that  this  artery  alone  was  in 
fault  An  opinion  which  induced  us  to  hint,  that  the  ar- 
teria  innominata  might  be  tied,  but  the  boldness  of  the 
operation,  and  the  deficiency  of  data  whereupon  to  esti- 
mate the  probability  of  its  issue,  forbade  us  to  urge  the 
proposition. 


OF  THE  HEAD  AND  NECK. 


73 


As  to  the  practicability  of  passing  a ligature  round  that 
artery,  we  had  no  hesitation,  and  experiments  made  on  the 
dead  subject,  convinced  us  that  we  had  nothing  to  dread 
in  regard  to  the  arm  being  supplied  with  blood;  but  there 
was  still  another  consideration,  which  we  were  entirely 
without  the  means  of  solving.  We  had  no  proof  of  the 
effects  which  would  be  produced  on  the  brain,  by  suddenly 
cutting  off  the  supply  of  blood  from  two  of  its  vessels. 
"We  well  knew  that  the  circulation  along  the  carotid  artery, 
might  be  intercepted  without  detriment  to  that  organ,  but 
we  possessed  no  testimony  that  both  it  and  the  vertebral 
artery  might  be  tied  with  equal  impunity.  Yet,  in  so  des- 
perate a disease  as  aneurism  of  the  subclavian  artery,  es- 
pecially where  it  had  a decided  tendency  to  extend  toward 
the  chest,  we  thought  it  allowable  to  risk  applying  a liga- 
ture round  the  arteria  innominata;  we  are  still  of  the  same 
opinion,  but  it  is  an  operation  which  ought  not  to  be  rashly 
undertaken.* 

I have  related  the  present  case  as  a warning  to  all  sur- 
geons; and  I have  to  add,  that  in  subclavian  aneurism  an 
operation  ought  never  to  be  advised,  unless  where  the  fin- 
gers can  be  insinuated  between  the  tumour  and  the  chest, 
and  even  then  the  arteria  innominata  ought  to  be  tied, 
without  any  very  sanguine  expectations  of  success.  There 
are  many  causes  which  tend  to  lessen  the  probability  of 
this  operation  having  the  desired  effect.  In  aneurism  about 
the  extremities,  we  can  completely,  or  nearly  completely, 
intercept  the  flow  of  blood  through  the  sac.  But  in  aneu- 
rism at  the  commencement  of  the  right  subclavian  artery, 
tying  the  arteria  innominata  has  no  such  control  over  the 
circulation.  By  passing  a thread  round  that  vessel,  we 
may,  indeed,  very  materially  lessen  the  quantity  of  blood 
sent  into  the  sac;  but  while  the  common  carotid  and  verte- 


'X 

A 

A 


10 


See  Appendix,  (B.) 


74 


ON  THE  SURGICAL  ANATOMY 


bral  arteries  remain  unsecured,  the  retrogade  circulation 
through  the  tumour  must  be  considerable.  Our  only  pros- 
pect of  success,  therefore,  when  we  tie  the  arteria  inno- 
minata,  is  founded  on  the  natural  tendency  which  the  con- 
tents of  the  aneurism  have  to  coagulation — a tendency 
winch  will  be  increased  by  rendering  the  circulation  more 
languid,  and  which,  perhaps,  may  ultimately  transfer  the 
circulation  into  a new  channel.  With  this  slender  expec- 
tation we  can  alone  undertake  this  operation.  Some  pa- 
tients may  prefer  the  chance  of  recovery  it  affords,  to  cer- 
tain death  from  the  extension  of  the  disease;  but  no  sur- 
geon can  conscientiously  urge  submission — that  ought  to 
be  a voluntary  choice  of  the  patient,  formed  after  a full  and 
explicit  acquaintance  with  the  danger. 

PLATE  II.  exhibits  a posterior  view  of  the  same  aneu- 
ism.  It  is  intended  to  illustrate  the  way  in  which  the  ar- 
teria innominata  A,  is  connected  with  the  tumour,  and  how 
the  sac  extended  upward  between  the  right  carotid  artery 
B,  and  the  right  subclavian  C,  and  the  sternum  by  which 
both  of  these  vessels  were  forced  backward  against  the 
spine.  In  this  view  there  is  also  represented  the  slight 
dilatation  found  at  the  root  of  the  subclavian  artery,  and 
the  contracted  diameter  of  the  vessel  more  remote  from  its 
origin.  D,  the  vena  cava  superior  is  seen  squeezed  and 
displaced  by  the  tumour.  E,  the  trachea,  and  F,  the  oeso- 
phagus are  both  greatly  displaced  by  the  distension  of  the 
sac. 

As  the  other  parts  of  the  engraving  have  little  reference 
to  the  disease  I shall  pass  them  over  without  further  notice. 

Sketch  III.  I have  added  from  the  case  which  occurred 
to  Mr.  Astley  Cooper.  It  is  not  to  be  considered  as  af- 
fording a representation  of  the  actual  appearance  of  the 
disease,  it  is  merely  a plan  illustrative  of  the  locality  of 
the  tumour  A,  which  is  seen  arising  by  a very  narrow  neck 
from  the  arch  of  the  aorta,  between  the  roots  of  the  left 


Platt  3. 


J^narai'fd  br  J-Crnt . 


■ - 

' 


• - . ■ 


■ , ' 


1 


- ■* 


' _ 

' 


Tlate  J 


m-  THE  HEAD  AND  NECK.  75 

subclavian  artery  B,  and  the  left  carotid  artery  C.  It 
pushed  up  between  these  vessels,  and  appeared  at  the  root 
of  the  neck,  so  that  it  resembled  an  aneurism  of  the  carotid 
artery  more  than  an  aneurism  of  the  aorta. 

These  Sketches  are  highly  valuable,  as  they  shew  the 
great  difficulty  in  distinguishing  aneurism  of  the  aorta  from 
aneurism  of  one  of  the  large  arteries.  In  the  latter  case, 
even  if  the  disease  had  really  been  seated  in  the  carotid  or 
subclavian  artery,  no  operation  could,  with  any  degree  of 
propriety,  have  been  undertaken.  From  the  closeness  of 
the  connexion  of  the  arteries  at  the  root  of  the  neck,  on 
the  left  side,  with  the  visceral  nerves  and  the  thoracic  duct, 
it  would  be  madness  to  attempt  to  pass  a thread  round 
either  of  them  verv  near  to  the  chest. 


When  the  occiput  is  turned  back,  if  we  draw 
a line  from  the  angle  of  the  jaw  to  the  spot 
where  the  clavicle  touches  the  coracoid  process 
of  the  scapula,  and  if  we  trace  another  from 
about  half  an  inch  behind  the  mastoid  process  to 
the  acromial  edge  of  the  origin  of  the  sterno- mas- 
toid muscle,  and  extend  another  along  the  upper 
margin  of  the  clavicle,  a triangular  portion  of 
the  side  of  the  neck  is  marked,  in  which  many 
important  parts  are  lodged. 

In  cutting  into  this  space,  the  skin  and  fascia 
require  to  be  first  divided  and  turned  back. 
When  this  is  done,  the  space  itself  is  seen  to  be 
divided  into  two  unequal  portions  by  the  poste- 
rior belly  of  the  omo-hyoideus.  The  course  of 


76 


ON  THE  SURGICAL  ANATOMY 


this  muscle  is  easily  discovered  on  the  living 
body,  by  drawing  a line  from  the  junction  of  the 
clavicle  and  coracoid  process,  to  the  sterno-mas- 
toid  muscle,  two  inches  in  the  adult  above  the 
sternum.  Above  this  line  there  is  only  lodged 
some  small  conglobate  glands,  some  trifling 
branches  of  nerves,  the  arteria  transversalis  colli, 
and  often  the  arteria  cervicalis  superficialis.  Be- 
low it,  nearer  to  the  clavicle,  there  is  found  the 
subclavian  plexus  of  nerves,  and  the  great  artery. 
The  nerves  at  this  part  lie  clustered  and  inter- 
laced above  and  behind  the  artery. 

It  is  in  this  confined  space  that  the  incision  is 
to  be  made,  and  the  artery  detached  from  the 
nerves  when  a ligature  is  to  be  passed  round  it, 
after  it  has  passed  from  between  the  scaleni  mus- 
cles; and  it  is  here  that  tumours  seated  belowT  the 
fascia  are  so  dangerous  to  extirpate.  They  are 
then  deeply  nitched  in  and  connected  with  parts 
with  which  we  would  not  wish  to  intermeddle. 
This  remark  is  only,  however,  applicable  to  those 
tumours  which  are  formed  beneath  the  fascia; 
those  which  are  subcutaneous,  circumscribed, 
and  moveable,  may  even  when  very  large  be 
easily  extirpated.  When,  however,  any  of  the 
deep-seated  glands  enlarge,  the  tumour  is  formed 
behind  the  posterior  belly  of  the  omo-hvoideus 
muscle,  is  bound  down  by  it  and  the  fascia,  con- 
tinues for  a length  of  time  flat,  and  is  long 
forming  an  external  projection.  At  last  it  does 


Fig  1 


/m-./y; 


OF  THE  HEAD  AND  NECK. 


77 


protrude  outwardly,  pushing  before  it  the  omo- 
hyoideus  muscle,  by  which  the  acromial  margin 
of  the  sterno-mastoid  is  turned  forward,  its  clavi- 
cular portion  is  pulled  up  on  the  side  of  the  tu- 
mour, and  carried  away  from  the  sternal  part. 
This  position  of  the  sterno-mastoid  depends  on 
the  connexion  of  the  omo-hyoideus  with  that  mus- 
cle. Wherever,  therefore,  the  sterno-mastoid  is 
seen  pulled  over  a tumour  situated  between  that 
muscle  and  the  trapedzius,  the  surgeon  may  be 
certain  that  it  is  deeper  seated  than  the  omo- 
hyoideus. 

The  position  of  the  tumour,  and  the  change 
produced  on  the  course  of  the  clavicular  portion 
of  the  sterno-mastoid  muscle  are  very  perfectly 
represented  in  an  excellent  cast  taken  by  Profes- 
sor Thomson  from  one  of  his  patients.  From  this 
cast,  I had,  by  his  permission,  a drawing,  taken 
from  which  plate  4th,  fig.  1.  has  been  engraved. 
In  this  plate,  A represents  the  clavicle,  a little 
above  which  B marks  the  most  prominent  part  of 
the  tumour. — C denotes  the  clavicular  portion  of 
the  sterno-mastoid,  which,  by  the  protrusion  of 
the  omo-hyoideus  is  pulled  awTay  from  the  sternal 
part,  describing  a curve  along  the  tracheal  side 
of  the  tumour.  The  tumour,  in  this  case,  is 
braced  back  on  the  arteria  transversalis  colli, 
the  arteria  cervicalis  superficialis,  the  upper  se- 
ries of  the  subclavian  plexus  of  nerves,  and  on 
the  posterior  branch  of  the  fourth  pair  of  cervical 


78 


ON  THE  SURGICAL  ANATOMY 


nerves.  Had  it  been  higher  it  would  have  been 
entirely  unconnected  with  the  large  nerves,  and 
had  it  been  lower  it  would  not  only  have  been  in 
contact  with  the  subclavian  plexus  of  nerves,  but 
it  would  also  have  touched  the  artery. 

In  this  triangular  space,  the  tumour  being  cov- 
ered by  the  fascia,  renders  it  difficult  to  ascer- 
tain with  precision  its  attachments.  By  the 
tenseness  of  the  sheath  spread  over  it,  we  are 
prevented  from  moving  it  fully  from  side  to  side, 
neither  can  we  pull  it  from  its  bason.  We  may, 
however,  in  some  degree,  judge  of  its  connex- 
ions, from  its  size,  duration,  and  effects  on  the 
arm.  Its  adhesion  to  the  branches  of  the  arte- 
ries or  nerves,  can  never  be  discovered,  but  we 
can  generally  ascertain  whether  it  be  connected 
with  the  large  artery,  or  subclavian  plexus  of 
nerves.  By  grasping  the  swelling  with  the  left 
hand,  while  we  push  the  fore  and  middle  finger  of 
the  right  hand,  deep  behind  the  clavicle,  we 
can  usually  touch  the  subclavian  artery,  and  by 
moving  the  tumour  from  side  to  side,  as  freely 
as  the  fascia  will  permit,  we  discover  whether  in 
its  motions,  it  drags  the  vessel  along  with  it.  If 
the  pulsation  remain  unchangeably  in  the  same 
spot,  we  may  reasonably  infer,  that  the  morbid 
parts  are  free  from  adhesion  to  the  great  artery, 
and  if  the  arm  be  not  benumbed,  there  is  reason 
to  hope  that  the  nerves  are  free  from  adhesion  to 
the  tumour. 


OF  THE  HEAD  AND  NECK» 


79 


It  is  only,  however,  in  those  cases  where  the 
tumour  has  not  enlarged  so  far,  as  to  be  jammed 
in  behind  the  clavicle,  that  any  approximation 
can  be  made  to  the  nature  of  its  adhesion. 
Where  the  tumour  has  originally  been  formed  by 
enlargement  of  a gland,  seated  just  above  the  cla- 
vicle, it  is  not  only  physically  impossible  to  dis- 
cover its  connexions,  but  without  care,  even  its 
nature  may  be  mistaken.  A simple  glandular 
swelling  may,  from  its  being  affected  by  the  pul- 
sation of  the  artery,  be  conceived  to  arise  from 
aneurism  of  that  vessel.  This  I have  actually 
known  happen. 

I remember  the  case  of  a middle-aged  man,  in 
whom  a pretty  large  pulsating  tumour  appeared 
from  behind  the  sternal  extremity  of  the  left  cla- 
vicle. It  was  bigger  than  a hen’s  egg,  pulsated 
very  strongly,  and  produced  an  inequality  in  the 
pulse  at  the  wrist,  great  difficulty  in  swallowing, 
and  a slight  dyspnoea.  The  surgeon  had  no 
doubt  of  its  being  an  aneurism;  and  accordingly 
he  explained  to  the  man  his  danger,  and  the  great 
risk  he  would  run  of  the  tumour  bursting,  if  he 
fatigued  himself,  or  lived  freely.  On  the  faith  of 
this,  he  prevailed  on  the  patient  to  keep  quietly 
in  the  house,  and  persuaded  him  to  take  great 
care  of  himself,  and  regularly  once  a-day,  during 
some  months,  he  visited  him.  During  which 
time,  the  tumour  did  not  enlarge,  neither  did  the 


80 


ON  THE  SURGICAL  ANATOMY 


pulsation  become  either  more  violent  or  more 
obscure. 

This  tedious  restriction  being  not  altogether  to 
the  patient’s  mind,  and  as  he  did  not  perceive 
that  the  danger  was  such  as  had  been  represent- 
ed, he  began  to  entertain  an  opinion  of  his  own: 
he  walked  out,  and  ate  and  drank  as  plentifully 
as  his  means  would  permit,  and  found  that  the 
swelling,  in  place  of  enlarging,  as  had  been  pre- 
dicted, really  became  smaller,  the  pulsation  de- 
creased in  strength,  and,  in  the  end,  to  the  asto- 
nishment of  all  who  saw  him,  both  the  tumour  and 
beating  disappeared.  The  history  and  issue  of 
this  case,  proves  that  it  was  not  aneurism.  It 
was  merely  a glandular  swelling,  receiving  an 
impulse  from  an  artery  beneath  it,  an  occurrence 
by  no  means  rare  about  the  neck. 

In  extirpating  tumours  from  this  part  of  the 
neck,  so  soon  as  they  are  exposed  the  scalpel  is 
to  be  laid  aside.  Then  the  morbid  parts  are  to 
be  cautiously  detached  by  the  fingers,  tearing 
them  from  the  tracheal  toward  the  acromial  side, 
by  which  the  course  of  the  vessels  and  nerves  are 
followed.  After  the  tumour  has  been  in  this  way 
removed,  it  is  to  be  carefully  washed  and  exam- 
ined lest  any  of  the  morbid  substance  has 
been  torn,  and  left  behind.  Even  when  we  are 
satisfied  that  the  tumour  has  been  removed  en- 
tire, the  finger  is  to  be  run  over  the  wound,  to 
ascertain  that  no  enlarged  gland,  or  indurated 


OF  THE  HEAD  AND  NECK. 


81 


cellular  membrane  be  left.  But  here  it  is  proper 
to  remark,  that  the  ruptured  arteries,  which  are 
felt  like  small  hard  points  projecting  from  the 
wound,  are  not  to  be  confounded  with  specks  of 
diseased  matter. 

By  enlargement  of  the  little  glands  exterior  to 
the  fascia  over  this  angular  space,  or  over  the 
sterno-mastoid  muscle,  tumours  are  frequently 
formed.  Such  swellings,  even  when  large,  may 
be  very  easily  extirpated.  I remember,  how- 
ever, a curious  and  fatal  affection  of  one  of  these 
glands,  which  occurred  to  my  brother  several 
years  ago.  The  patient  was  a strong  and  athle- 
tic man,  who,  about  six  years  previous  to  his  ap- 
plication at  the  Royal  Infirmary,  had  received  a 
smart  blow  on  the  neck,  from  the  keel  of  a boat. 
This  injury  was  soon  followed  by  the  formation 
of  a firm,  tense  tumour,  on  the  place  which  had 
been  hurt.  The  swelling  increased  very  slowly 
during  the  five  years  immediately  succeeding  its 
commencement,  but  during  the  sixth,  it  received 
a very  rapid  addition  to  its  bulk.  At  this 
time  it  measured  nearly  six  inches  in  diameter, 
seemed  to  be  confined  by  a firm  and  dense  cover- 
ing, and  the  morbid  parts  had  an  obscure  fluctua- 
tion. From  first  to  last  the  tumour  had  been 
productive  of  very  little  pain. 

Judging  from  the  apparent  fluctuation,  that  the 
tumour  was  incysted,  it  was  resolved,  at  a con- 
sultation, to  puncture  the  swelling,  draw  off  its 
41 


82 


ON  THE  SURGICAL  ANATOMY 


contents,  and  then  pass  a seton  through  it.  By 
plunging  a lancet  into  it,  only,  a very  small  quan- 
tity of  blood,  partly  coagulated  and  partly  fluid, 
was  discharged, — a quantity  so  trifling,  that  after 
its  evacuation  the  size  of  the  tumour  was  not  per- 
ceptibly reduced.  A seton  was  passed  through 
the  swelling.  At  this  time  the  man  was  in  per- 
fect health. 

About  ten  hours  after  the  operation,  the  pa- 
tient was  seized  with  extremely  violent  rigors, 
followed  by  heat,  thirst,  pain  in  the  back,  exces- 
sive pain  in  the  tumour,  and  oppressive  sick- 
ness. 

An  emetic  was  prescribed,  but  instead  of  pro- 
ducing vomiting,  it  operated  as  a cathartic.  To 
remove  the  irritation,  the  seton  was  withdrawn. 
The  pain  in  the  tumour,  however,  and  the  ge- 
neral uneasiness  continued  to  increase,  and  thirty 
hours  after  making  the  puncture,  air  began  to 
issue  from  the  tract  of  the  seton;  and  afterwards 
the  cellular  membrane  of  the  neck,  and  of  the 
other  parts  of  the  body  in  succession,  became  dis- 
tended with  a gaseous  fluid.  In  the  course  of  a 
few  hours  after  the  commencement  of  the  general 
emphysema,  the  man  died. 

Twelve  hours  after  death,  when  the  body  was 
free  from  putrefaction,  it  was  inspected.  The 
emphysema  was  neither  increased  nor  diminished 
since  death,  and  some  idea  may  be  formed  of  its 
extent,  when  the  scrotum  was  distended  to  the 


OF  THE  HEAD  AND  NECK. 


83 


size  of  the  head  of  an  adult.  Even  the  cavities 
of  the  heart  and  the  canals  of  the  blood-vessels 
contained  a considerable  quantity  of  air.  We 
could  discover  no  direct  communication  between 
the  tumour  and  the  trachea  or  lungs,  although 
such  was  carefully  sought  for. 

This  is  not  an  unique  case.  Dr.  Baillie  gives 
the  history  of  one  which  occurred  in  a female,* 
and  another  is  to  be  found  detailed  by  Dr.  Hux- 
am  in  the  London  Medical  Observations  and  In- 
quiries. f Emphysema  was  also  witnessed  by 
W'lmer,  occurring  during  tedious  labour.!  Ih 
all  of  these  cases  it  would  appear  that  the  em- 
physema had  been  dependent  on  rupture  of  some 
of  the  bronchial  cells.  Portal  in  his  “Cours 
d’Anatomie  Medicale,’,||  and  in  his  Work  on 
Phthisis  Pulmonalis,§  has  shewn  that  a connex- 
ion does  subsist  between  the  cellular  texture  of 
the  lungs,  and  that  of  the  rest  of  the  body.  He 
has  proved  this  by  wounding  the  lungs  and  blow- 
ing air  into  their  substance,  for  in  this  way  he 
filled  the  cellular  membrane  of  the  neck  and 
arms.  Portal  does  not,  however,  applv  this  fact 
to  the  explanation  of  emphysema  not  dependent 
on  external  violence. 

* Transactions  of  the  Medical  Society  of  London,  vol.  i. 

t Huxham’s  Letter  to  Mr.  Leake,  London  Med.  Obs.  and  Inquiries, 
vol  iii. 

| MTmer’s  Observations  in  Surgery,  p.  143. 

||  Cours  d’Anatomie  Medicale,  vol.  ii.  p.  4. 

§ Observations  sur  La  Nature  et  Le  Traitement  de  La  Plithisie  Puli- 


jnonaire. 


84 


ON  THE  SURGICAL  ANATOMY 


Iii  my  brother’s  case  of  spontaneous  emphy- 
sema, and  in  Dr.  Huxham’s,  the  air  evidently 
spread  from  the  neck  to  the  other  parts;  and  in 
a case  lately  attended  by  Mr.  Russel  and  myself, 
where  we  had  an  opportunity  of  inspecting  the 
body  after  death,  we  had  a clear  demonstration 
of  the  passage  of  the  air  from  the  lungs  into  the 
cellular  membrane  of  the  neck.  In  this  child, 
during  the  struggles  for  breath,  which  preceded 
dissolution,  some  of  the  bronchial  cells  had  given 
way.  During  the  irregularities  of  breathing,  air 
was  forced  from  the  chest  into  the  cellular  mem- 
brane, about  the  lower  part  of  the  neck,  along 
which  it  diffused  itself,  producing  a swelling 
which  crackled  when  pressed  on  by  the  fingers. 

The  child  died  very  soon  after  the  neck  began 
to  fill  with  air;  consequently,  in  this  instance, 
emphysema  wras  partial.  Had  the  patient  lived 
long  enough,  there  can  be  no  doubt  that  it  would 
have  become  general. 

When  we  opened  the  body  within  twenty-four 
hours  after  death,  in  cold  winter  weather,  we  per- 
ceived no  sign  of  beginning  putrefaction,  but  we 
found  the  cellular  texture  of  the  lungs  distended 
with  air,  which  had  passed  along  into  the  medi- 
astinum. It  had  separated  the  laminae  of  this 
septum  to  a considerable  distance  from  each 
other.  Next,  it  had  mounted  between  these  folds, 
till  at  last  it  had  escaped  from  the  chest  behind 
the  sternum,  and  then  passing  through  the  small 


OP  THE  HEAD  AND  NECK. 


85 


apertures  in  the  cervical  fascia,  it  had  diffused 
itself  among  the  cellular  substance  of  the  neck. 

This  case  is  valuable,  since  it  shews  that  by 
mere  rupture  of  a few  of  the  bronchial  cells,  occa- 
sioned by  irregular  action  of  the  lungs,  or,  by  some 
other  internal  cause,  spontaneous  diffusion  of  the 
air  may  take  place.  It  illustrates  what  happened 
in  my  brothers  case,  and  it  throws  a new  light 
on  the  cases  on  record,  of  spontaneous  emphyse- 
ma; it  shews  that  they  are  dependent  on  the 
same  cause  which  gives  rise  to  emphysema,  ac- 
knowledged to  depend  on  injury  of  the  lungs: 
only,  in  the  one  case,  the  rupture  of  the  bronchial 
cells  is  produced  by  a less  obvious  cause  than  in 
the  other. 


The  relations  and  connexions  of  the  subclavian 
artery,  both  before  and  after  it  has  passed  from 
between  the  scaleni  muscles,  are  so  important, 
that  I have  added  a sketch  of  these  parts  from  a 
hoy. 

Plate  4th,  fig.  2.  When  preparing  this  view, 
the  subject  was  laid  on  its  back,  and  the  head  was 
permitted  to  hang  over  the  end  of  the  table.  In 
this  way,  all  the  parts  about  the  root  of  the  neck 
were  fairly  exposed.  A,  is  placed  on  the  clavicle. 
B,  marks  the  trachea.  C,  the  gullet.  D,  the  sea- 


86 


ON  THE  SURGICAL  ANATOMY 


lenus  anticus  muscle.  E,  the  arteria  innominata. 
F,  the  left  carotid  artery.  G,  the  left  subclavian 
artery,  after  it  has  passed  from  between  the  sca- 
leni  muscles.  H,  the  termination  of  the  internal 
jugular  vein.  I,  ti  e left  subclavian  vein,  which 
receives  K,  the  termination  of  the  thoracic  duct. 
The  duct  itself  is  seen  mounting  from  behind  the 
jugular  vein,  interposed  between  it  and  L,  the 
trunk  of  the  lower  thyroid  artery.  The  phrenic 
nerve  M,  and  the  nervus  vagus  N,  are  also  placed 
in  such  a relation  to  the  subclavian  artery,  before 
it  reaches  the  sealeni  muscles,  that  they  add  to 
the  perplexity  of  the  dissection  of  that  vessel. 
Indeed,  whoever  contemplates  these  parts,  will 
at  once  perceive  the  difficulty  of  including  the 
subclavian  artery  in  a ligature  nearer  to  the  chest 
than  the  sealeni  muscles.  It  has,  however,  been 
attempted,  but  without  success.  “The  name  of 
the  gentleman  who  operated  will  be  deemed  a 
sufficient  sanction  of  the  belief,  that  no  practica- 
ble means  of  relief  were  omitted/'* 

“In  a case  of  subclavian  aneurism,  which  lately 
occurred  in  Guy’s  Hospital,  Mr.  Astley  Cooper 
attempted  to  tie  the  subclavian  artery  above  the 
clavicle.  The  aneurism  was  very  large,  and  the 
clavicle  was  thrust  upward  by  the  tumour,  so  as 
to  make  it  impossible  to  pass  a ligature  under  the 
artery  without  incurring  the  risk  of  including 


* Annual  Medical  Review,  vol.  ii.  p.  4-7. 


OF  THE  HEAD  AND  NECK. 


87 


some  of  the  nerves  of  the  axillary  plexus.  The 
attempt  was  therefore  abandoned.”* 

Nearer  to  the  shoulder  than  the  scaleni  muscles 
the  subclavian  artery  is  seen  lying  interposed  be- 
tween O,  the  subclavian  plexus  of  nerves,  and  the 
subclavian  vein.  Here  we  see  that  the  connex- 
ions of  the  vessel  are  not  of  such  a nature  as  to 
render  an  attempt  to  pass  a ligature  round  it  im- 
proper. The  situation  of  the  artery  is,  neverthe- 
less, such  as  will  occasion  considerable  diffi- 
culty in  the  execution  of  this  design,  which  has, 
however,  happily  been  achieved  in  the  living  sub- 
ject, by  Mr.  Ramsden,  of  St.  Bartholomew’s 
Hospital. 

Mr.  Ramsden  has  published  the  case,  along 
with  some  other  interesting  surgical  observations. 
As  his  statement  is,  on  many  accounts,  valuable,  I 
here  take  the  liberty  of  transcribing  the  case,  to- 
gether with  the  history  of  the  operation,  in  the 
performance  of  which,  Mr.  Ramsden  experienced 
considerable  difficulty  from  the  want  of  a proper 
needle  to  convey  a ligature  round  the  artery. 
Those  who  wish  to  make  themselves  acquainted 
with  the  various  instruments  contrived  to  assist 
in  this  part  of  the  operation,  may  consult  Bichat’s 
edition  of  Desault’s  Works,  vol.  2d,  page  560, 
and  Mr.  Ramsden’s  Work,  where  several  are 
delineated  and  described. 


London  Medical  Recorder,  June,  1809, 


88 


ON  THE  SURGICAL  ANATOMY 


“ Case  of  Axillary  Aneurism,  in  which  the  Sub- 
clavian artery  was  tied. 

“This  case  did  not  prove  ultimately  success- 
ful; yet  as  all  the  more  immediate  objects  of  the 
operation  were  most  satifactorily  attained,  I have 
thought  it  right  to  submit  the  following  detail  to 
the  perusal  of  the  profession,  under  a presump- 
tion that  it  contains  several  practical  facts  of  con- 
siderable importance,  not  only  with  reference  to 
this  particular  operation,  but  also  to  our  future 
conduct,  in  all  cases  of  aneurism. 

“John  Townly,  a tailor,  aged  thirty-two  years, 
addicted  to  excessive  intoxication,  of  an  un- 
healthy and  peculiarly  anxious  countenance,  was 
admitted  into  St.  Bartholomew’s  Hospital,  on 
Tuesday  the  2d  of  November,  1809,  on  account 
of  an  aneurism  in  the  axilla  of  his  right  arm, 
which  had  been  coming,  he  said,  about  four 
months.  He  could  not  trace  its  origin  to  any  ac- 
cident; at  first,  he  supposed  the  swelling  to  be 
only  a common  bile,  and  therefore  paid  little  at- 
tention to  it,  until  the  pulsation  in  the  tumour, 
and  a distressing  tingling  sensation  in  the  ends  of 
his  fingers,  deprived  him  of  sleep,  and  rendered 
him  incapable  of  working  at  his  trade. 

“When  he  was  received  into  the  hospital,  the 
prominent  part  of  the  tumour  in  the  axilla  was  of 
the  size  of  the  half  of  a large  orange;  there  was 
also  a very  considerable  enlargement  and  disten- 


OF  THE  HEAD  AND  NECK. 


ss 


sion  under  the  pectoral  muscle  and  adjacent 
parts,  which  prevented  the  elbow  from  being 
brought  by  the  distance  of  several  inches,  into 
contact  with  the  side. 

“The  temperature  of  both  arms  was  alike,  and 
the  pulse  in  the  radial  artery  of  each  of  them 
was  correspondent.  After  the  patient  had  been 
put  to  bed,  some  blood  taken  from  the  left  arm, 
and  his  bowels  emptied,  his  pulse,  which  on  his 
admission,  had  been  at  130,  became  less  frequent; 
his  countenance  appeared  more  tranquil;  and  he 
experienced  some  remission  of  the  distressing 
sensations  in  the  affected  arm;  this  relief  was, 
however,  of  short  duration;  the  weight  and  in- 
cumbrance of  his  arm  soon  became  more  and 
more  oppressive,  and  in  resistance  to  every  me- 
dical assistance,  his  nights  were  again  passed 
without  sleep,  and  his  countenance  resumed  the 
anxiety  which  had  characterized  it,  when  he  first 
presented  himself  for  advice. 

“On  the  sixth  day  after  his  admission,  his  de- 
cline of  health  became  so  very  evident,  and  the 
progressive  elevation  of  the  clavicle,  from  the 
increasing  bulk  of  the  tumour,  was  so  decidedly 
creating  additional  difficulties  to  any  future  ope- 
ration, that  I considered  it  necessary  to  convene 
my  colleagues,  and  avail  myself  of  their  opinions, 
as  to  the  propriety  of  performing  the  operation; 
when  it  was  agreed,  in  consultation,  that  as  the 
tumour  (although  increasing)  did  not  appear  ini- 
12 


90 


ON  THE  SURGICAL  ANATOMY 


mediately  to  endanger  the  life  of  the  patient,  from 
any  probability  of  its  bursting  suddenly,  it  would 
be  advisable  yet  to  postpone  the  operation  for  the 
purpose  of  allowing  the  greatest  possible  time  for 
the  anastomosing  vessels  to  become  enlarged;  and 
in  the  mean  while,  that  the  case  should  be  most 
regularly  watched. 

“About  this  period  of  the  case,  the  pulsation 
of  the  radial  artery  of  the  affected  arm  gradually 
became  more  obscure,  and  soon  after  either 
ceased  entirely,  or,  what  is  more  probable,  was 
lost  in  the  succeeding  oedema  of  the  fore  arm  and 
hand,  both  of  which  became  loaded  to  a great 
extent.  Notwithstanding  the  aneurismal  tumour 
had  continued  to  increase,  and  the  patient's 
health  had  proportionally  declined,  yet  no  parti- 
cular alteration  was  observed  on  the  integuments, 
until  I visited  him  in  the  evening  of  the  twelfth 
day  after  his  admission,  when  I found  him  com- 
plaining of  more  than  usual  weariness  and  weight 
in  the  affected  limb,  and  painfully  impatient,  from 
the  impossibility,  as  he  described  it,  of  finding  a 
posture  for  his  arm. 

“On  examining  the  tumour,  a dark  spot  ap- 
peared on  its  centre,  surrounded  by  inflammation, 
which  threatened  a more  extensive  destruction 
of  the  skin.  Under  these  symptoms  and  appear- 
ances, no  further  postponement  of  the  operation 
being  admissible,  I performed  it  next  day  in  the 
following  manner. 


OP  THE  HEAD  AND  NECK. 


91 


“Of  the  Operation . 

“The  patient  being  placed  upon  the  operating 
table,  with  his  head  obliquely  toward  the  light, 
and  the  affected  arm  supported  by  an  assistant  at 
an  easy  distance  from  the  side,  I made  a trans- 
verse incision  through  the  skin  and  platysma  my- 
oides,  along  and  upon  the  upper  edge  of  the  cla- 
vicle, of  about  two  inches  and  a half  in  length, 
beginning  it  nearest  to  the  shoulder,  and  termi- 
nating its  inner  extremity  at  about  half  an  inch 
within  the  outward  edge  of  the  sterno-cleido- 
mastoideus  muscle.  This  incision  divided  a small 
superficial  artery,  which  was  directly  secured. 
The  skin,  above  the  clavicle  being  then  pinched 
up  between  my  own  thumb  and  finger,  and  those 
of  an  assistant,  I divided  it  from  within  outwards 
and  upwards,  in  the  line  of  the  outer  edge  of  the 
sterno-cleido-mastoideus  muscle,  to  the  extent  of 
two  inches, 

“My  object  in  pinching  up  the  skin  for  the 
second  incision,  was  to  expose  at  once  the  super- 
ficial veins,  and  by  dissecting  them  carefully  from 
the  cellular  membrane,  to  place  them  out  of  my 
way  without  wounding  them.  This  provision 
proved  to  be  very  useful,  for  it  rendered  the  flow 
of  blood,  during  the  operation,  very  trifling,  com- 
paratively with  what  might  otherwise  have  been 
expected;  and  therefore  enabled  me  with  the 


02 


ON  THE  SURGICAL  ANATOMY 


greatest  facility,  to  bring  into  view  those  parts 
which  were  to  direct  me  to  the  artery. 

“My  assistant  having  now  lowered  the  shoul- 
der,* for  the  purpose  of  placing  the  first  incision 
above  the  clavicle,  (which  I had  designedly  made 
along  and  upon  that  bone,)  I continued  the  dis- 
section with  my  scalpel,  until  I had  distinctly 
brought  into  sight  the  edge  of  the  anterior  scale- 
nus muscle,  immediately  below  the  angle  which 
it  formed  by  the  traversing  belly  of  the  omo-hy- 
oideus  and  the  edge  of  the  sterno-cleido-mastoi- 
deus,  and  having  placed  my  finger  on  the  artery 
at  the  point  where  it  presents  itself  between  the 
scaleni,  I found  no  difliculy  in  tracing  it  without 
touching  any  of  the  nerves  to  the  lower  edge 
of  the  upper  rib,  at  which  part  I detached  it  with 
my  finger  nail,  for  the  purpose  of  applying  the 
ligature. 

“Here,  however,  an  embarrassment  arose, 
which  (although  I was  not  unprepared  for  it) 
greatly  exceeded  my  expectation.  I had  learn- 
ed, from  repeatedly  performing  this  operation, 
many  years  since  on  the  dead  subject,  that  to  pass 
the  ligature  under  the  subclavian  artery  with  the 
needle  commonly  used  in  aneurisms,  would  be 
impracticable;  I had  therefore  provided  myself 
with  instruments  of  various  forms  and  curvatures, 

* In  my  first  incision  I intentionally  cut  down  along  and  upon  the  clavi- 
cle, as  a security  against  wounding  any  superficial  vessels;  a very  little 
lowering  of  the  shoulder,  therefore,  placed  the  incision  in  the  situation  I 
wished  to  have  it,  for  the  purpose  of  proceeding  with  the  operation. 


OF  THE  HEAD  AND  NECK. 


93 


to  meet  the  difficulty,  each  of  which  most  readily 
conveyed  the  ligature  underneath  the  artery,  but 
could  serve  me  no  farther;  for,  being  made  of 
solid  materials,  and  fixed  into  handles,  they 
would  not  allow  of  their  points  begin  brought  up 
again  at  the  very  short  curvature  which  the  nar- 
rowness of  the  space  between  the  clavicle  and 
the  rib  afforded,  and  which,  in  this  particular 
case,  was  rendered  of  unusual  depth  by  the  pre- 
vious elevation  of  the  shoulder  by  the  tumour. 

“After  trying  various  means  to  overcome  this 
difficulty,  a probe  of  ductile  metal  was  at  length 
handed  me,  which  I passed  under  the  artery,  and 
bringing  up  its  point  with  a pair  of  small  forceps, 
I succeeded  in  passing  on  the  ligature,  and  then 
tied  the  subclavian  artery  at  the  part  where  I 
had  previously  detached  it  for  that  purpose.  The 
drawing  of  the  knot  was  unattended  with  pain, 
the  wound  was  closed  by  the  dry  suture,  and  the 
patient  was  then  returned  to  bed, 

“* Appearances  after  Death. 

“On  examination  of  the  body  after  death,  but 
few  peculiarities  presented  themselves;  some  of 
them,  however,  appear  to  me  to  be  well-deserv- 
ing our  attention. 

“The  subclavian  artery,  excepting  at  the  aneu- 
rismal  aperture,  was  in  a perfectly  healthy  state. 
The  arteries  branching  off  from  it,  on  which  the 
limb  was  to  be  dependent  for  its  future  support, 


94 


ON  THE  SURGICAL  ANATOMY 


had  not  acquired  any  increase  of  capacity  beyond 
that  which  is  natural  to  them.  The  heart,  and 
large  vessels  immediately  in  connexion  with  it, 
were  perfectly  sound,  but  on  opening  the  vena 
cava  superior,  it  was  found  to  contain  a large 
body  of  coagulable  lymph,  firmly  adherent  to  its 
internal  coat,  and  hanging  pendulous  into  the 
auricle,  where  it  applied  itself  like  a valve,  and 
totally  obstructed  the  communication  between  the 
auricle  and  the  ventricle. 

‘‘The  aneurismal  tumour  contained  about  two 
pints  of  blood,  the  greater  part  of  which  was  ill 
so  fluid  a state,  that  it  escaped  through  a small 
puncture  which  I made  with  my  scalpel.  The 
front  of  the  tumour  was  covered  with  a strongly 
connected  substance,  bearing  some  resemblance  to 
a sac,  but  its  posterior,  and  other  boundaries, 
were  formed  merely  of  those  parts  (unaltered 
from  their  healthy  state)  with  which  the  effused 
blood  had  happened  to  come  into  contact. 

“The  subclavian  artery,  where  the  ligature  was 
applied,  was  so  very  nearly  separated,  that  it  was 
only  held  together  by  a few  shreds  of  dead  matter. 
Each  extremity  of  the  almost  divided  artery,  on 
"being  laid  open,  was  found  to  be  already  com- 
pletely consolidated  and  impervious,  and  no  doubt 
could  exist  of  its  being  at  this  period,  fully  com- 
petent to  resist  the  impetus  of  the  blood  from  the 
heart.  I had  also  to  remark,  at  these  extremi- 
ties, a small  deposit  of  coagulable  lymph,  which 


OF  THE  HEAD  AND  NECK. 


95 


was  closely  connected  with  the  internal  coat  of  the 
vessel,  and  seemed  to  be  placed  there  as  an  ad- 
ditional means  of  securing  its  obliteration.”* 


After  the  description  of  the  surgical  anatomy 
and  relations  of  the  subclavian  artery  and  neigh- 
bouring parts,  I am  next  led  to  attend  to  the  si- 
tuation of  the  deep-seated  parts  about  the  neck 
and  face.  In  prosecuting  this  inquiry,  the  dif- 
ferences in  the  relation  of  these  parts,  as  depen- 
dent on  age,  and  change  of  position  of  the  head, 
must  be  pointed  out. 

As  the  adult  is  to  be  considered  the  most  per- 
fect in  formation,  I shall  first  describe  the  parts 
as  found  at-  that  period  of  life,  and  then  notice 
the  variations  dependent  on  age  and  other  cir- 
cumstances. 

In  the  living  person,  in  whom  no  part  about 
the  throat  is  called  into  action,  and  in  whom  the 
base  of  the  skull  is  placed  parallel  to  the  horizon, 

* Since  the  publication  of  Mr.  Ramsden’s  work,  a considerable  number 
of  cases  have  been  published,  where  the  subclavian  artery  after  passing 
the  scaleni  muscles  has  been  tied.  It  must  be  confessed,  that  the  majority 
of  these  have  terminated  unsuccessfully,  yet  as  the  disease,  for  the  cure  of 
w hich  this  operation  is  performed,  is  one  of  a nature  which  w ould  speedily 
prove  fatal  were  it  not  practised,  no  argument  can  be  urged  against  its 
propriety  from  its  frequent  failure.  A very  interesting  case  where  the 
operation  was  successfully  performed  by  Dr.  Post,  the  able  professor  of 
Anatomy  in  the  University  of  New  York,  will  be  found  in  the  ninth 
volume  of  the  Medico  Chirurgical  Transactions,  p.  J 85. — Ed. 


96  ON  THE  SURGICAL  ANATOMY 

the  os  hyoides  can  he  felt  through  the  integu- 
ments, situated  about  four  finger-breadths  behind 
the  chin,  and  about  a quarter  of  an  inch  lower  in 
the  throat  than  the  margin  of  the  jaw-bone.  The 
upper  prominent  edge  of  the  thyroid  cartilage  is 
traced,  beginning  about  half  an  inch  below  the 
base  of  the  hyoid  bone,  and  is  found,  by  follow- 
ing it  with  the  finger,  gradually  sloping  back- 
ward, and  declining  from  the  perpendicular  as  it 
descends.  Between  the  os  hyoides  and  thyroid 
cartilage,  there  is,  on  the  fore  part  of  the  throat, 
a little  hollow  or  vacuity,  but  laterally  no  defi- 
ciency can  be  perceived.  Just  below  the  thyroid 
cartilage,  a similar  but  smaller  hollow  is  felt. 
About  three  or  four  lines  lower  than  the  inferior 
edge  of  the  thyroid  cartilage,  the  cricoid  carti- 
lage is  discovered,  forming  a prominent  semicir- 
cle, resembling  the  body  of  the  os  hyoides.  Next, 
by  insinuating  the  finger  and  thumb  between  the 
margins  of  the  sterno* mastoid  muscles,  we  feel, 
just  a little  below  the  cricoid  cartilage,  a sub- 
stance of  a doughy  consistence;  but  in  the  living 
subject,  and  in  the  healthy  state  of  parts,  its 
limits  are  by  no  means  well  defined.  It  is  pro- 
duced by,  and  marks  the  position  of,  the  thyroid 
gland.  Between  the  sterno-mastoid  muscles,  and 
below  the  thyroid  gland,  a hollow  is  felt,  angular 
in  its  figure,  containing  the  trachea:  the  point 

where  we  enter  the  windpipe,  in  performing  the 
operation  of  tracheotomy. 


OP  THE  HEAD  AND  NECK. 


97 


All  these  parts  can  be  easily  distinguished  on 
the  living  body,  and  consequently,  the  relation  of 
the  one  to  the  other  may  be  ascertained.  In  a 
full  grown  male,  six  linger-breadths  will  generally 
he  found  between  the  upper  margin  of  the  thyroid 
cartilage  and  the  sternum.  By  dividing  this  into 
two  equal  portions,  we  define  the  superior  border 
of  the  thyroid  gland,  and  by  allowing  a single 
breadth  of  the  finger  for  the  average  breadth  of 
the  gland  itself,  a space  capable  of  admitting  two 
fingers,  is  only  left  below  the  gland  and  above 
the  sternum. 

In  performing  operations  on  the  throat,  the 
head  is  seldom  placed  with  the  base  of  the  skull 
parallel  to  the  horizon,  it  is  generally  inclined  at 
a considerable  angle,  which  materially  alters  the 
position  of  the  parts  about  the  neck.  When  the 
occiput  is  fully  turned  back,  the  space  between 
the  chin  and  the  chest  is  so  greatly  increased 
that  twelve  fingers  can  be  placed  between  them. 
When  the  head  is  in  this  position,  there  is  merely 
an  oblique  line  running  from  the  chin  to  the  ster- 
num, and  presenting,  in  its  course,  small  projec* 
tions,  formed  by  the  prominent  points  of  the  car- 
tilages of  the  larynx.  When  the  base  of  the  skull 
is  placed  parallel  to  the  horizon,  the  thyroid  carg 
tilage  lies  somewhat  more  than  three  finger- 
breadths  behind  the  chin;  but  when  the  occiput 
is  turned  back,  if  a thread  be  extended  from  the 
chin  to  the  sternum,  the  thumb  alone  can  be 
13 


0 N THE  SURGICAL  ANATOMY 


introduced  between  it  and  the  thyroid  cartilage. 
When  the  head  is  in  this  position,  rather  more 
than  four,  hut  less  than  five  fingers,  can  be  placed 
between  the  chin  and  the  upper  margin  of  the 
thyroid  cartilage.  Somewhat  more  than  three  fin- 
gers can  he  laid  between  the  top  of  the  thyroid 
cartilage  and  the  superior  border  of  the  thyroid 
gland, — then,  after  deducting  a single  breadth 
of  the  finger  for  the  breadth  of  the  gland,  three 
finger-breadths  remain  between  the  lower  edge 
of  the  gland  and  the  highest  point  of  the  sternum. 
This  statement,  I have  reason  to  believe,  from 
repeated  examinations  made  both  on  the  living 
and  dead  body,  forms  a pretty  near  approxima- 
tion to  the  truth.  From  this  view  of  the  subject 
it  appears,  that  by  bending  hack  the  head  to  its 
maximum,  we  increase,  by  one  breadth  of  the 
finger,  the  space  in  which  we  perform  the  ope- 
ration of  tracheotomy. 

By  removing  the  integuments,  external  jugu- 
lar veins,  platysma  myoides,  and  fascia,  we  ex- 
pose the  deep-seated  parts.  We  bring  first  into 
view  the  sterno- mastoid  muscle,  which  some  way 
above  the  chect  is  crossed  posteriorly  by  the  omo- 
hyoideus.  These  muscles  generally  decussate  each 
other  nearly  opposite  to  the  upper  margin  of  the 
cricoid  cartilage,  and  about  four  finger-breadths 
above  the  clavicle.  The  latter  is,  however,  a 
very  uncertain  rule,  since  the  relative  distance  of 
the  clavicie  and  jaw  is  liable  to  variation  in  dif 


OF  THE  MEAD  AND  NECK. 


99 


'ferent  bodies.  Yet,  as  the  point  of  crossing  of 
these  muscles,  fixes  a point  in  the  position  of 
the  vessels  of  the  neck,  it  is  desirable  that  we 
be  able  to  make  a near  approximation  to  the  spot 
on  the  living  subject.  By  laying  a thread  from 
the  anterior  part  of  the  mastoid  process  to  the 
centre  of  the  upper  bone  of  the  sternum,  and  by 
extending  another  from  the  side  of  the  body  of 
the  os  hyoides  to  a little  nearer  the  sternum  than 
the  central  part  of  the  clavicle,  we  describe 
pretty  accurately  the  course  of  the  muscles. 
The  first  thread  defines  the  anterior  margin  of 
the  sterno-mastoid,  while  the  other  follows  the 
direction  of  the  omo-hyoideus.  lust  beneath  the 
point  of  intersection  of  these  two  lines,  the  com- 
mon carotid  is  generally  placed — I say,  generally, 
for  I would  not  wish  to  inculcate,  that  it  is  an  in- 
variable occurrence.  It  is,  however,  so  frequent, 
that  it  is  of  consequence  that  the  operator  know 
how  it  is  to  be  discovered.  Above  this  spot  the 
course  of  the  artery  may  be  discovered,  by  laying 
a thread  from  the  point  of  decussation  up  to  the 
jaw-bone.  Lower  in  the  neck  we  have  no  certain 
rule  by  which  to  discover  the  situation  of  the 
carotid. 

The  common  carotid  artery,  from  the  root  of 
the  neck  up  to  the  spot  where  it  bifurcates,  is 
surrounded  by  large  vessels  and  important  nerves. 
The  nerves  are  the  ramus  descendens  noni,  the 
nervus  vagus,  and  the  sympathetic.  Along  the 


100 


ON  THE  SURGICAL  ANATOMY 


whole  course  of  the  common  carotid  we  find  the 
nervus  vagus,  and  the  large  internal  jugular  vein 
inclosed  in  a cellular  sheath,  along  with  the  caro- 
tid artery.  The  sympathetic  nerve  lies  exterior 
to  the  sheath,  between  it  and  the  longus  colli 
muscle,  to  which  it  is  joined  by  cellular  mem- 
brane. That  the  sympathetic  nerve  is  not  in- 
closed in  the  vascular  sheath  may  be  demonstrat- 
ed by  a very  simple  experiment.  Let  the  front  of 
the  sheath  be  exposed,  then  grasp  it  between  the 
blades  of  a pair  of  dressing  forceps,  and  pull  it 
forward;  now,  by  examination  it  will  be  found, 
that,  along  with  the  sheath,  the  carotid  artery, 
the  jugular  vein,  the  descendens  noni,  and  the 
nervus  vagus,  will  be  drawn  away  from  the  spine, 
while  the  sympathetic  remains  attached  to  the 
muscle  behind. 

The  jugular  vein  lies  on  the  acromial  side  of 
the  carotid  artery;  the  nervus  vagus  lies  between 
the  vein  and  the  artery,  and  the  artery  itself  is 
placed  next  to  the  trachea;  the  ramus  descendens 
noni  runs  down  on  the  fore  part  of  the  carotid, 
forming  a beautiful  series  of  fibrillse  over  the  omo- 
hyoideus,  sterno-hyoideus,  and  sterno-thyroideus 
muscles, — a plexus  inimitably  delineated  by  Scar- 
pa, in  his  splendid  work  on  the  nerves  of  the 
neck. 

The  ramus  descendens  noni,  generally,  just 
above  the  point  of  decussation  of  the  sterno- 
mastoid  and  omo-hyoideus,  receives  additions, 


OF  THE  HEAD  AND  NECK. 


101 


sometimes  from  the  second  and  third  of  the  cer- 
vical nerves,  but  at  other  times  only  from  the 
latter  of  these  nerves.  These  twigs  pass  along 
between  the  common  carotid  artery  and  internal 
jugular  vein.  Where  they  join  the  descendens 
noni,  a little  swelling  is  generally  formed,  from 
which  twigs  are  sent  off  in  every  direction  to  the 
neighbouring  muscles.  Sometimes  this  nerve  is 
contained  in  the  carotid  sheath,  but  frequently  it 
is  placed  exterior  to  it,  in  which  case,  the  com- 
municating twigs  from  the  cervical  nerves  cross 
on  the  fore  part  of  the  internal  jugular  vein,  not 
inclosed  in  the  sheath. 

In  pointing  out  the  depth  of  the  artery,  vein, 
and  nerves,  at  different  parts  of  the  neck,  it  will 
be  necessary  to  divide  the  latter  into  three  sup- 
posititious regions;  a lower,  a middle,  and  an 
upper.  The  middle  region  will  be  defined  by 
drawing  a line  from  the  root  of  the  mastoid  pro- 
cess to  the  junction  of  the  horn  with  the  body 
of  the  os  hyoides,  by  running  another  from  the 
anterior  edge  of  the  mastoid  process  to  the  cen- 
tre of  the  upper  bone  of  the  sternum,  and  by 
extending  a third  from  the  side  of  the  body  of 
the  hyoid  bone,  to  near  the  centre  of  the  clavicle. 
By  these  three  lines  a portion  of  the  side  of  the 
neck,  nearly  of  a triangular  shape,  is  insulated. 

Along  the  whole  extent  of  this  which  forms  the 
middle  region  of  the  neck,  the  carotid  artery  is 
accompanied  by  the  nerves  and  jugular  vein,  as 


102  ON  THE  SURGICAL.  ANATOMY 

already  described,  and  in  this  situation,  these  parte 
are  very  superficial,  they  are  merely  covered  by 
the  integuments,  the  platysma-myoides,  the  fascia 
of  the  neck,  and  their  own  cellular  sheath. 

Here,  then,  is  the  proper  spot,  provided  the 
place  be  in  our  choice,  to  lay  bare  the  vessel  to 
take  it  up.  Lower  in  the  neck  it  is  deeper 
seated,  and  higher  it  is  sunk  behind  the  angle  of 
the  jaw.  At  the  lower  part  of  the  neck,  be- 
sides the  integuments,  the  platysma  myoides, 
the  fascia,  and  the  common  sheath,  the  artery 
is  covered  by  the  sterno- mastoid,  the  sterno- 
thyroid, and  the  omo-hyoid  muscles.  Hence, 
it  is  really  deeper  in  the  lower  region  of  the 
neck  than  in  the  middle,  although  Mr.  John 
Bell  asserts,  that  the  carotid  becomes  deeper 
the  further  it  retreats  from  the  chest.  Mr. 
Bell’s  description  is  only  applicable  to  a front 
view  of  the  neck,  in  which  case,  as  the  larynx 
projects,  the  artery  seems  to  be  thrown  back: 
but  let  any  one  look  at  these  parts  in  profile,  and 
he  will  instantly  be  convinced  that  this  is  an  ex- 
ceedingly incorrect  description.  Although,  how- 
ever, the  carotid  lies  deeper  at  the  lower,  than  at 
the  middle  part  of  the  neck,  it  is  more  readily, 
in  attempts  to  commit  suicide,  reached  at  the 
former,  than  at  the  latter  place,  where,  unless 
the  knife  be  plunged  into  the  side  of  the  neck, 
the  firm  cartilages  of  the  larynx  guard  the  artery 


OF  THE  HEAI>  AND  NECK. 


1 03 


from  injury.  Below  the  triangular  space,  the 
knife  passes  through  the  less  solid  substance. 

In  the  lower  region  of  the  neck  the  carotid 
artery  on  the  left  side  lies  just  on  the  outer 
edge  of  the  oesophagus,  which  is  seen  in  Plate 
4th,  fig.  2,  projecting  from  beneath  the  trachea. 
It  is  covered  by  twigs  of  the  recurrent  nerve, 
and  crossed  by  the  lower  thyroid  artery,  which 
traverses  it  in  its  course  to  the  gland.  Just  at 
the  commencement  of  the  gullet,  the  left  lobe 
of  the  thyroid  gland  is  laid  over  its  surface,  and 
supported  in  contact  with  it  by  the  ribbon-like 
sterno  thyroid  muscle.  Beneath  the  muscle,  be- 
tween it  and  the  oesophagus,  a cluster  of  small 
conglobate  glands  are  situated. 

These  glands  sometimes  enlarge,  producing, 
from  the  bracing  of  the  muscle,  very  serious  diffi- 
culty in  swallowing.  When  they  enlarge,  the  tu- 
mour formed  is  deep-seated,  and  in  two  cases 
which  I have  seen,  the  swellings  seemed,  from 
the  condition  of  the  muscles  covering  them,  to  be 
more  diffused  than  they  really  were.  Such  tu- 
mours frequently  suppurate,  forming  a deep-seat- 
ed abscess,  in  which  fluctuation  can  hardly  be 
perceived,  and  which  generally  bursts  into  some 
part  deeper  seated  than  the  fascia.  The  matter  is 
by  no  means  unfrequently  poured  into  the  gullet  or 
trachea,  or  even  into  the  jugular  vein,  as  we  learn 
from  a case  related  in  one  of  the  periodical  publi- 
cations. In  a case  where  the  abscess  had  burst 


104  ON  THE  SURGICAL  ANATOMY 

into  the  trachea,  the  patient  could  inflate  the  sac, 
he  was  teased  with  cough,  expectorated  purulent 
cough,  and  died  hectic.  From  the  risk  of  the 
abscess  bursting  into  one  or  other  of  the  parts 
mentioned,  it  is  at  all  times  advisable  to  promote 
resolution;  but  where  this  cannot  be  accomplished 
when  an  abscess  forms,  it  is  to  be  kept  in  remem- 
brance, that  if  the  surgeon  delay  till  fluctuation 
become  distinct,  he  may  have  waited  too  long. 
So  soon,  therefore,  as  there  is  just  reason  to  be- 
lieve that  pus  is  formed,  it  must  be  discharged  by 
an  opening  cautiously  made  into  the  sac;  I say 
cautiously,  as  I have  seen  the  ramus  thyroideus  of 
the  lower  thyroid  artery  projected  before  an  ab- 
scess in  that  part  of  the  neck. 

Where  the  tumour  is  of  a specific  nature,  early 
extirpation  will  be  the  only  hope  of  saving  the 
patient.  Indeed,  it  is  only  in  the  first  stage  of 
such  a tumour,  that  an  operation  would  be  ad- 
visable. Where  the  tumour  is  already  large,  it 
will  have  come  in  contact  with  the  thyroid  gland, 
with  the  common  sheath  of  the  vessels  and  nerves, 
will  be  closely  connected  with  the  recurrent 
nerve,  the  ramus  thyroideus  of  the  inferior  thy- 
roid artery,  and  the  gullet.  Although  any  of 
these  connexions,  considered  individually,  would 
not  be  deemed  sufficient  to  prohibit  the  extirpa- 
tion of  the  morbid  parts,  yet,  when  they  are 
viewed  collectively,  few  will  hesitate  as  to  the 
propriety  of  declining  an  operation. 


OP  THE  HEAD  AND  NECK, 


105 


The  pharynx  does  not  terminate  in  the  oeso- 
phagus till  it  has  passed  the  lower  border  of  the 
cricoid  cartilage,  nor  does  it  even  there  suddenly 
contract.  For  some  way  above,  it  had  been  gra- 
dually  tapering,  so  that  at  last  the  transition 
from  the  expanded  pharynx  into  the  narrow 
gullet  is  far  from  being  abrupt.  Yet  the  change 
is  so  great,  that  a substance  which  has  passed 
the  tapering  part  of  the  pharynx  will  be  detained 
in  the  upper  part  of  the  oesophagus.  This  will 
require  to  be  fixed  on  the  memory;  as  it  explains 
the  reason  why  a solid  morsel  of  food,  or  other 
bulky  substance,  is  detained  just  below  the  ter- 
mination of  the  larynx.  If  it  pass  the  beginning 
of  the  oesophagus,  it  may,  uniformly,  where  the 
gullet  is  not  strictured  nearer  the  stomach,  be 
pushed  into  that  viscus  by  the  probang.  But  if 
it  stick  just  at  the  top  of  the  oesophagus,  it  is 
there  too  low  to  be  laid  hold  of  by  the  finger,  and 
even  curved  forceps  can  hardly  be  so  applied  as 
to  extract  the  foreign  body,  neither  will  the  pro- 
bang enable  us  to  force  it  into  the  stomach;  or 
granting  that  it  would,  we  may  have  reasons  for 
not  wishing  to  place  it  there. 

Where,  therefore,  an  extraneous  substance  has 
become  firmly  impacted  in  the  top  of  the  gullet, 
and  where  it  is  so  placed  that  it  prevents  the  de- 
scent of  food  into  the  stomach,  or,  by  its  pressure 
on  the  trachea,  obstructs  breathing,  there  ought 
to  be  no  hesitaton  in  performing  the  operation  of 
14 


106 


ON  THE  SURGICAL  ANATOMY 


oesophagotomy; — an  operation  which  a careful 
review  of  the  anatomy  of  the  neck,  and  a due 
regard  to  the  circumstances  under  which  it  is  had 
recourse  to,  will  induce  one  to  believe  has  been 
generally  much  over-rated  in  its  danger.  The 
surgeon  is  not  from  this  to  suppose  that  it  is  the 
simplest  operation  in  surgery;  yet  I would  as 
unwillingly  have  him  imagine  that  it  is  one  of  the 
most  difficult  in  its  execution.  Let  him  attentively 
examine  the  relation  of  the  parts  around  the 
gullet,  and  let  him  take  into  consideration  the 
condition  in  which  the  oesophagus  itself  is  placed, 
and  he  will  be  convinced  that  oesophagotomy 
may,  with  perfect  safety,  be  performed.  The 
gullet,  where  projected  from  behind  the  trachea, 
is  covered  by  the  twigs  of  the  recurrent  nerve, 
and  traversed  by  the  thyroid  branch  of  the  lower 
thyroid  artery,  which  are  really  the  principal 
parts  to  be  avoided  in  performing  this  opera- 
tion. I have  no  fear  that  injury  of  these  would 
influence  the  ultimate  success  of  the  operation;  but 
as  no  good  can  possibly  be  derived  from  their 
division,  and  as  such  may  be  productive  of  harm, 
the  surgeon  can  have  no  excuse  for  not  avoiding 
them.  The  pulsation  of  the  artery  will  lead  to  a 
knowledge  of  its  situation,  and  the  nerve  may  be 
detected  by  sponging  away  the  blood.  But  one 
who  digs  behind  the  sternal  muscles  with  the 
scalpel,  can  sc  rcely  a\  oid  cutting  these  parts;  nay, 
one  who  does  not  recollect  that  where  cesophago- 


OP  THE  HEAD  AND  NECK. 


107 


toray  is  really  required,  the  gullet  is,  at  the  part 
where  it  ought  to  be  entered,  distended,  aud 
consequently  brought  into  close  contact  with,  and 
firmly  pressed  against  these  muscles,  will  be  very 
liable  at  the  time  he  penetrates  the  muscles,  to 
injure  the  parts  behind.  In  executing  this  part 
of  the  operation,  the  greatest  caution  is  required, 
and  the  subsequent  exposure  of  the  gullet,  ought 
to  be  entirely  done  with  the  finger,  nor  ought  the 
scalpel  to  be  again  taken  up,  nor  any  attempt 
made  to  open  the  oesophagus,  till  the  position  of 
both  the  recurrent  nerve,  and  the  thyroid  branch 
of  the  lower  thyroid  artery  has  been  ascertained, 
and  the  lateral  lobe  of  tire  thyroid  gland  be  turned 
aside.  This  will  be  indispensably  necessary,  as 
that  portion  of  the  gland  rests  on  the  very  com- 
mencement of  the  gullet.  I consider  as  peurile, 
the  opinion  that  the  carotid  is  in  danger;  he 
must  be  wanton,  indeed,  in  the  use  of  his  knife, 
who  hurts  this  vessel.  It  is  evident,  that  this 
dread  does  not  arise  from  the  actual  examina- 
tion of  a body,  in  which  a foreign  substance 
is  impacted  in  the  gullet.  In  such,  the  carotid, 
it  will  be  observed,  is  fairly  pushed  to  a side 
by  the  swelling;  it  is  quite  out  of  the  reach 
of  injury,  unless  an  attempt  be  made  to  cut  into 
the  oesophagus,  very  low  indeed  in  the  neck. 
Just  above  the  chest,  the  gullet  is  rather  over- 
lapped bv  the  common  carotid;  here,  therefore, 
there  may  be  some  danger  of  wounding  that  ves° 


108 


ON  THE  SURGICAL  ANATOMY 


sel,  but  this  is  a part  where  no  one  in  his  senses 
would  ever  propose  to  open  the  oesophagus. 
That  must  be  done  higher  in  the  neck,  at  a point 
where  the  carotid  is  perfectly  safe. 

Much  of  the  reasoning  in  regard  to  this  ope- 
ration, has  been  drawn  from  the  contemplation  of 
the  relations  of  the  oesophagus  to  the  neighbour- 
ing parts  in  a state  of  health.  It  has  seldom 
been  taken  into  account,  that  the  distension  of  the 
gullet  renders  the  operation  safer.  The  foreign 
substance  is,  in  fact,  as  much  a guide  in  entering 
the  gullet,  as  the  staff  is  in  performing  the  opera- 
tion of  lithotomy  Were  the  oesophagus  empty 
and  contracted,  then,  no  doubt,  the  dissection  re- 
quired to  reach  it  would  be  deeper;  but  still,  there 
is  nothing  which  ought  to  render  it  hazardous  to 
accomplish,  and  nothing  which  would  deter  one 
who  knew  the  parts  as  he  ought  to  do,  from  un- 
dertaking its  performance.  That  it  may  be  safe- 
ly accomplished,  does  not  rest  on  such  speculative 
evidence.  It  has  on  different  occasions  been  exe- 
cuted on  the  living  subject,  and  has  succeeded. 
Let  not,  therefore,  its  expediency  be  questioned, 
nor  its  safety  doubted.  I wish  to  impress  the 
student  with  the  belief,  that  cesophagotomy  is  an 
operation  neither  dangerous,  nor  very  difficult  in 
its  performance;  but  I would,  at  the  same  time 
assure  him,  that  the  ease  and  safety  with  which 
it  may  be  executed,  will  be  entirely  regulated  by 
his  own  knowledge  of  the  locality  of  the  parts  he 
has  to  cut. 


OF  THE  HEAD  AND  NECK. 


109 


The  surgeon  must  not  only  keep  in  remem- 
brance the  usual  relation  of  parts  about  the  neck, 
but  he  must  also  be  aware,  that  there  are  varie- 
ties in  the  distribution  of  the  arteries,  by  which 
branches  are  brought  within  reach  of  the  knife, 
which  naturally  ought  not  to  be  there.  I have 
never  read  of  any  instance  of  this  kind,  but  have 
once  seen  an  anomalous  vessel  placed,  so  that 
it  was  in  danger  of  being  hurt.  The  case  to 
which  I allude,  is  at  present  before  me.  The 
subject  is  aged  between  ten  and  twelve  years. 
In  it  an  artery,  rather  larger  than  a crow  quill,, 
rising  from  the  very  root  of  the  arteria  innominata, 
mounting  up  along  the  trachea  between  it  and 
the  sternal  muscles,  a little  below  the  thyroid 
gland,  it  suddenly  turns  aside,  places  itself  over 
the  oesophagus,  and  creeps  up  along  it,  so  as  at 
last  to  touch  the  lower  margin  of  the  left  lateral 
lobe  of  the  thyroid  gland.  It  is  demonstrable,  that 
had  cesophagotomy  been^required  on  this  person, 
this  artery  would  probably  have  been  injured. 
But  although  it  would  have  poured  out  a consi- 
derable quantity  of  blood,  still  the  ligature  could 
easily  have  been  applied,  and  it  ought  to  have 
been  applied  before  the  gullet  itself  was  opened. 

For  a description  of  the  manner  in  which  the 
operation  is  to  be  performed,  and  for  a detail  of 
the  after-treatment;  and  also  an  account  of  the 
way  in  which  extraneous  bodies,  not  of  such  a 
nature  as  to  require  cesophagotomy,  are  to  he 


110  ON  THE  SURGICAL  ANATOMY 

removed,  I refer  to  the  different  works  on  Sur- 
gery. 

In  the  middle  region  of  the  neck,  there  are 
lodged,  besides  the  ramus  descendens  noni,  the 
nervus  vagus,  the  sympathetic  nerve,  and  the 
jugular  vein,  some  other  parts  which  will  require 
to  be  enumerated.  Nearly  opposite  to  the  divi- 
sion of  the  common  carotid  artery,  the  superior 
cervical  ganglion  of  the  sympathetic  nerve,  sends 
off  a slender  branch,  which  descends  along  the 
tracheal  margin  of  the  great  artery,  and  receiv- 
ing numerous  twigs  from  all  the  nerves  in  the 
vicinity,  it  becomes  at  length  of  considerable  size.* 
At  the  root  of  the  neck,  it  is  especially  inter- 
woven with  the  twigs  of  the  recurrent  nerve,  and 
then  by  attaching  itself  to  the  aorta,  it  is  conduct- 
ed to  the  heart.  Anatomists  have  chosen  to 
name  it  the  nervus  superficialis  cordis,  and  I 
would  add,  that  it  is  a nerve,  which,  on  account 
of  the  valuable  function  of  the  organ  on  which  it 
is  distributed,  ought,  in  every  operation,  to  be 
avoided.  There  are  no  experiments  indeed  to 
prove  the  effect  which  would  result  from  injury  of 
this  nerve,  but  analogical  experience  would  lead 
us  to  suppose,  that  it  would  be  highly  injurious, 
if  not  absolutely  fatal. 

The  upper  laryngeal  nerve  emerges  from  be- 
hind the  internal  carotid,  a few  lines  above  the 

* The  nervus  superficialis  cordis  occasionally  takes  its  origin  from  the 
lower  cervical  ganglion. — Ed. 


OF  THE  HEAD  AND  NECK. 


Ill 


upper  border  of  the  thyroid  cartilage,  and  directly 
slips  in  behind  the  hyo-thyroideus  muscle,  along 
with  the  superior  laryngeal  artery.  A twig  from 
the  eighth  pair,  about  the  size  of  the  fourth  pair, 
accompanies  the  ramus  thyroideus  of  the  superior 
thyroid  artery. 

Along  the  whole  of  the  middle  region  of  the 
neck,  the  common  carotid  artery  is  accompanied 
by  the  glandulse  coneatenatse.  Some  of  this  chain 
lie  anterior  to  the  vessel,  while  others  are  inter- 
posed between  it  and  the  spine.  When  one  of 
these  glands  enlarge,  the  tumour,  from  its  con- 
nexion with  the  large  artery,  has  some  of  the 
characters  of  aneurism,  and  is  often  mistaken 
for  that  disease.  I have  now  had  occasion  to 
see  several  such  cases.  I may  mention  the  out- 
lines of  one.  The  patient,  a female,  advanced 
to  middle  age,  had,  for  several  months,  com- 
plained  of  a slight  degree  of  pain  and  fulness 
on  the  left  side  of  the  thyroid  cartilage.  These 
she  had  neglected,  till,  at  last,  a perceptible 
swelling  was  formed  on  the  side  of  the  neck. 
When  I saw  her,  the  tumour  was  about  the  size 
of  a large  walnut,  and  it  seemed  to  have  a 
strong  pulsation.  That  it  was  alternately  raised 
and  depressed  by  the  action  of  the  carotid,  was 
most  evident,  and  that  it  was  an  aneurism  of  that 
vessel,  several  who  saw  it,  and  who  satisfied 
themselves  with  a superficial  examination,  firmly 
believed.  Indeed,  as  it  seemed  to  pulsate,  few. 


1 12 


ON  THE  SURGICAL  ANATOMY 


unless  warned  of  the  ambiguous  nature  of  tu* 
mours  here,  would  have  doubted  that  it  had  ori- 
ginated from  a disease  of  the  artery.  It  was 
only  by  a careful  examination,  that  its  apparent, 
could  be  distinguished  from  real,  pulsation.  One 
who  grasped  the  part  between  the  fingers,  was 
readily  convinced  that  although  the  swelling  was 
elevated  and  depressed,  the  rising  and  falling 
did  not  depend  on  any  variation  in  the  magni- 
tude of  the  swelling  itself.  It  was  satisfactorily 
perceived  to  depend  on  the  action  communicated 
from  the  carotid  to  the  tumour.  By  lateral  pres- 
sure, the  size  of  the  tumour  could  not  be  reduced, 
but,  by  pulling  it  forward,  removing  the  swelling 
from  the  sphere  of  action  of  the  large  artery, 
all  trace  of  pulsation  was  destroyed.  This  was 
decisive  of  its  real  nature,  and  in  this  way, 
a glandular  tumour,  which,  apparently  pulsates, 
can  always  be  readily  distinguished  from  aneu- 
rism. In  the  latter  case,  the  swelling  continues 
to  beat,  it  becomes  alternately  tense  and  puffed 
up,  and  smaller  and  more  flaccid.  Whereas  the 
diameter  of  a glandular  tumour  never  varies,  it 
is  solid  in  its  consistence,  and  is  uniformly  in- 
compressible. 

I have  no  doubt  that  some  of  the  reputed 
cases  of  aneurism,  in  which  spontaneous  reco- 
very took  place,  had  been  merely  glandular 
tumours,  placed  over  the  course  of  a large  ar- 
tery, and  receiving  an  impulse  from  the  vessel 


op  the  Head  and  neck,  „113 

beneath.  It  occurs  to  me,  that  this  was  the 
real  nature  of  the  tumours  described  by  Dr.  He- 
berden,  which  arose  in  the  neck  without  any 
obvious  cause,  which  continued  for  a length  of 
time  stationary,  seeming  to  pulsate,  and  which 
slowly  disappeared  without  either  suppurating 
or  bursting.  Indeed,  in  every  case  of  glandular 
tumour,  placed  over  the  course  of  a large  ar- 
tery, the  swelling  seems  to  have  a stronger  pul- 
sation than  the  artery  itself,  provided  it  be  not 
buried  beneath  thick  and  strong  muscles.  In 
the  groin,  the  ham,  and  the  middle  region  of 
the  neck,  the  apparent  pulsation  of  such  tu- 
mours is  frequently  most  furious.  Where,  how- 
ever, the  swelling  forms  above  the  line  of  the 
digastric  muscle,  or  beneath  the  point  of  decus- 
sation of  the  sterno-mastoid  muscle  by  the  omo- 
hyoideus,  then,  as  the  glands  and  vessel  are 
deep  seated,  the  pulsation  is  more  obscure.  Even 
tumours,  formed  in  the  middle  region  of  the 
neck,  lose  their  apparent  pulsation,  when  they 
have  acquired  a large  size.  Their  pressure  im- 
pedes the  action  of  the  artery,  and  they  become 
too  bulky  to  be  affected  by  the  systole  or  diastole 
of  the  vessel.  The  only  circumstances  under 
which  a large  tumour  can  retain  its  seeming  pul- 
sation, is  the  artery  being  projected  on  the  front 
of  the  swelling.  But  here  there  can  be  no  diffi- 
culty in  distinguishing  the  disease  from  aneu- 
rism. The  defined  course  of  the  pulsation,  its 
15 


114  ON  THE  SURGICAL  ANATOMY 

being  only  felt  along  a particular  part  of  the  swel- 
ling, and  the  unchangeable  nature  of  the  tumour, 
lead  to  an  acquaintance  with  the  disease.  The 
symptoms  are,  indeed,  such  as  would  only  lead 
the  most  ignorant  to  a supposition  of  aneurism. 

From  the  locality  of  tumours  produced  by  en- 
largement of  the  glandulae  concatenatse,  respira- 
tion and  deglutition  are  soon  affected;  and  it  will 
generally  be  found,  that  by  the  pressure  of  the 
swelling  on  the  nervus  vagus,  and  the  sympa- 
thetic nerve,  the  functions  of  the  chylopoietic. 
viscera  are  impaired.  From  these  considerations, 
the  most  vigorous  measures  must  be  pursued  for 
their  removal,  and  these  means  must  be  varied 
according  to  the  nature  of  the  tumour,  and  the 
object  we  have  in  view.  Where  we  are  foiled  in 
our  attempts  to  get  rid  of  them  without  operation, 
they  must  be  extirpated;  but  it  is  to  be  remem- 
bered, that  this  can  only  be  safely  accomplished 
in  the  early  stage  of  the  complaint. 

If  tbe  tumour  has  been  permitted  to  become 
large,  it  will  be  found  firmly  fixed  to  the  muscles, 
nerves,  and  vessels  in  the  vicinity;  its  adhesions 
are  then  such,  that  no  prudent  operator  would  at- 
tempt excision.  The  first  point  to  be  ascertained, 
is,  whether  the  tumour  be  free  from  adhesion  to 
the  artery.  In  emaciated  subjects,  this  is  very 
easily  done.  The  tumour  is  to  be  grasped  be- 
tween the  fingers  of  the  right  hand,  while  a finger 
of  the  left  is  to  be  placed  over  the  artery,  just 


OF  THE  HEAD  AND  NECK. 


115 

below  the  swelling;  then  by  moving  the  tumour  from 
side  to  side,  and  pulling  it  outward,  its  relation 
to  the  vessel  will  be  ascertained.  If  the  artery 
roll  along  with  the  morbid  parts,  an  operation  is 
out  of  the  question;*  but  when  it  remains  sta- 
tionary, if  other  circumstances  be  favourable,  the 
tumour  may  be  taken  away.  Where  the  gland 
has  originally  been  placed  behind  the  carotid,  it 
will  often  be  found  that  the  tumour  has  risen  up 
on  each  side  of  the  artery,  so  as  to  bury  it,  the 
jugular  vein,  the  nervus  vagus,  and  the  ramus  de- 
descendens  noni  in  the  very  centre  of  the  morbid 
parts.  This  I have  myself  observed,  while  dis- 
secting such  a tumour,  and  if  I have  not  been 
misinformed,  one  surgeon,  from  neglecting  to  as- 
certain the  connexion  of  the  swelling,  met  with  a 
similar  occurrence,  while  performing  the  opera- 
tion on  the  living  subject. 

Let,  therefore,  no  one  resolve  on  the  removal 
of  any  tumour  from  beneath  the  fascia,  at  the  side 
of  the  neck,  till  he  has  previously  fully  ascertained 
all  its  connexions.  If  these  be  found  such  as  to 
warrant  the  performance  of  an  operation,  let  not 
procrastination  destroy  the  hope  of  the  patient 

* Mr.  Burns’  observations  as  to  the  impropriety  of  attempting  the  re- 
moval of  a tumour,  when  we  have  ascertained  that  it  is  connected  with 
the  carotid  artery,  go  a g-reat  deal  too  far.  The  connexion  of  the  artery 
with  the  tumour,  or  even  the  vessel  being  surrounded  by  its  substance, 
should  not  offer  to  the  dextrous  surgeon,  an  insurmountable  objection 
against  an  operation  for  its  extirpation,  when  he  is  satisfied  that  this  i: 
required  for  the  safety  of  the  patient. — F.d, 


116 


ON  THE  SURGICAL  ANATOMY 


Proceed  without  delay  to  its  extirpation,  place  the 
patient  in  a proper  position,  make  then  an  in- 
cision through  the  integuments,  the  platysma  rny- 
oides,  and  the  fascia,  down  to  the  tumour,  which 
next  expose,  by  dissecting  back  the  parts  which 
cover  it.  Now,  lay  aside  the  knife,  act  with  bold- 
ness and  decision,  grasp  the  tumour  firmly  with 
the  fingers  and  thumb  of  the  right  hand,  ascertain 
that  the  hold  is  secure,  and  instantly  and  steadily 
wrench  it  from  its  attachments  behind.  This,  if 
executed  with  proper  rapidity,  is  not  more  pain- 
ful than  the  more  tedious  removal  with  the  scalpel 
would  have  been,  is  seldom  followed  by  bleeding, 
and  is  infinitely  less  dangerous;  indeed,  so  fully 
convinced  are  the  best  and  most  expert  surgeons 
of  the  truth  of  this,  that  few  of  them  now,  in  ex- 
tirpating tumours  from  the  neck  or  axilla,  employ 
the  knife,  after  the  external  incision  has  been 
made. 

In  the  middle  region  of  the  neck  a small  gland 
is  found,  seldom  larger  in  its  healthy  state  than 
a millet  seed,  but  which  will  require  to  have  its 
connexions  pointed  out.  This  gland  is  placed 
between  the  os  hyoides  and  thyroid  cartilage, 
lying  beneath  the  hyo-thyroideus  muscle,  imbed- 
ded in  much  fat,  and  merely  separated  from  the 
epiglottis  and  bag  of  the  pharynx  by  the  thin 
membrane  which  is  stretched  from  the  hyoid 
bone  to  the  thyroid  cartilage.  When  this  gland 
enlarges,  as  it  is  firmly  braced  down  by  the  hyo- 


OF  THE  HEAD  AND  NECK. 


11? 


thyroideus  muscle,  by  the  cervical  fascia,  and 
by  the  platysma  myoides,  its  effects  on  the  func- 
tion of  deglutition  and  respiration  are  most  dread- 
ful. A few  months  ago,  I dissected  a body,  in 
which  this  gland  was  affected  with  fungus  hsema- 
todes,  but  as  the  tumour  was  small,  and  the  dis- 
ease in  the  incipient  stage,  the  discovery  of  the 
morbid  parts  was  accidental.  Some  years  ago, 
I saw  a similar  affection  of  this  gland  in  a female, 
the  particulars  of  whose  case  I select  from  my 
brother’s  notes,  taken  during  the  progress  of  the 
disease. 

The  patient,  who  was  of  an  emaciated  look, 
and  sallow  complexion,  began,  about  eleven 
months  ago,  to  complain  of  uneasiness  in  swal- 
lowing, and  slight  pain  on  pressing  the  throat; 
but  till  within  the  last  six  months  she  neither 
perceived  any  fulness  nor  swelling  about  the 
neck. 

Now,  on  examination,  there  is  a firm,  elastic 
tumour,  about  the  size  of  a large  walnut,  and  ra- 
ther flat,  perceived  on  the  left  side  of  the  thyroid 
cartilage.  It  adheres  firmly  to  it,  and  covers 
nearly  three-fourths  of  its  lateral  flap,  and  it  oc- 
cupies all  the  space  between  the  hyoid  bone  and 
the  thyroid  cartilage;  so  that  by  thrusting  the 
finger  deep  behind  the  mouth,  the  tumour  is 
felt  projecting  into  the  pharynx,  placed  a little 
below  the  angle  of  the  jaw,  and  lying  close  on 


118  ON  THE  SURGICAL  ANATOMY 

the  arytcenoid  cartilage  and  root  of  the  epig- 
lottis. 

On  pressing  the  tumour,  it  obstructs  respira- 
tion, and  at  all  times  it  produces  a hoarse,  whiz- 
zing noise;  yet  from  the  greater  pliancy  of  the 
pharynx,  it  particularly  affects  deglutition,  ren- 
dering this  uniformly  difficult  and  painful.  From 
its  effects  on  the  velum  when  she  attempts  to 
swallow  fluids,  part  of  them  pass  back  into  the 
nose,  and  sometimes  even  escape  by  the  nostril. 
The  swelling,  which  of  late  has  been  increasing 
in  size,  is  attended  with  reiterated  paroxysms  of 
lancinating  pain,  so  severe,  that  her  rest  is  bro- 
ken, and  the  body  drenched  in  perspiration. 

As  the  disease  advanced,  the  tumour  hardly 
became  larger  externally,  but  it  continued  to  en- 
croach more  and  more  on  the  pharynx,  and  finally 
destroyed  the  patient,  by  its  effects  on  breathing 
and  swallowing. 

On  dissection,  which  was  performed  in  the 
presence  of  Dr.  Cleghorn,  the  morbid  parts, 
which  were  of  a soft  medullary  structure,  a grey- 
ish colour,  and  enclosed  in  a membranous  cap- 
sule, presented  the  appearance  of  two  tumours: 
one  situated  in  the  original  position  of  the  gland: 
the  other,  and  larger,  lying  more  in  the  place  of 
the  pharynx.  It,  indeed,  protruded  inward  the 
thin  membrane  stretched  from  the  os-hyoides  to 
the  thyroid  cartilage,  so  as  to  fill  nearly  the 
whole  bag  of  the  pharynx.  It  covered  the  left 


OP  THE  HEAD  AND  NECK, 


119 


wing  of  the  thyroid  cartilage,  and  by  its  pressure 
on  the  epiglottis  and  arytcenoid  cartilage,  nearly 
obliterated  the  rirna  glottidis. 

As  description  cannot  convey  any  defined  idea 
of  the  connexions  of  the  morbid  parts,  I add  the 
following  sketches,  which  were  takei>  from  the 
recent  parts,  and  which  shew  accurately,  the  re- 
lations of  the  tumour  to  the  parts  in  the  vicinity. 


DESCRIPTION  OF  PLATE  V. 

FIGURE  FIRST. 

A,  the  external  division  of  the  tumour,  which  has  been 
brought  into  view  by  removing  the  integuments,  the  fascia, 
and  the  platysma  myoides. — B,  the  horn  of  the  os  hyoides. 
E,  the  hyo-thyroideus  muscle. — F,  the  sterno  thyroideus. — 
G,  the  omo-hyoideus. — H,  the  common  carotid  artery. — I, 
the  ramus  thyroideus  of  the  upper  thyroid  artery,  which  in 
this  subject,  arises  an  independent  vessel  from  the  common 
carotid.  It  is  very  small,  and  in  its  course  to  the  thyroid 
gland,  it  traverses  the  lower  edge  of  the  tumour. — K,  the 
external  carotid  artery. — L,  the  ramus  laryngeus  superior, 
which  arises  from  the  external  carotid,  and  is  seen  plunging 
into  the  sulcus,  which  divides  the  tumour  into  two  por- 
tions.— It  is  large,  and  it  is  also  worthy  of  being  remarked 
that  it  is  the  only  vessel  connected  with  the  tumour.  The 
nerve  which  accompanied  it,  has  been  removed,  but  it  was 
in  every  respect  healthy. — M,  the  lingual,  and  N,  the  labial 
artery,  both  of  which  run  above  the  horn  of  the  hyoid  bone, 
and  consequently  are  removed  from  the  morbid  parts. 


120 


ON  THE  SURGICAL  ANATOMY 


Tlie  veins  corresponding  to  the  arteries  were  varicose, 
but  the  conglobate  glands  were  unaffected. 

DESCRIPTION  OF  FIGURE  SECOND. 

To  obtain  this  view,  the  sides  and  back  part  of  the  pha- 
rynx have  been  removed.  A,  that  large  portion  of  the  tu- 
mour which  occupied  the  bag  of  the  pharynx,  now  fully  ex- 
posed, by  dissecting  away  the  thin  membrane  which  was 
stretched  from  the  hyoid  bone,  to  the  thyroid  cartilage,  and 
which  is  seen  flattened  on  its  posterior  surface,  by  rest- 
ing on  the  spine,  between  which,  and  the  tumour,  there 
was  merely  the  back  part  of  the  pharynx  interposed. — B, 
the  root  of  the  tongue. — C,  the  epiglottis  distorted  by  the 
pressure  of  the  tumour. — D,  the  glottis  exposed,  by  push- 
ing the  tumour  aside  by  a slip  of  whalebone. — E,  the  right 
wing  of  the  thyroid  cartilage  showing  the  small  space  be- 
tween the  tumour  and  it,  even  when  the  former  has  been 
displaced  by  the  whalebone.  The  relation  of  the  morbid 
parts  to  the  glottis  and  to  the  pharynx,  will  at  once  explain 
the  induction  of  the  dyspnoea  and  dysphagia,  and  will  shew 
that  little  of  the  food  could  be  transmitted  into  F,  the 
gullet,  into  which  a piece  of  wood  has  been  introduced. 
As  the  other  parts  can  be  readily  traced  from  their  relation 
<o  those  lettered,  it  will  be  unnecessary  to  specify  them. 


The  history  and  dissection  of  this  case  I have 
fully  detailed,  as  it  will,  along  with  many  others, 
establish  the  position,  that  tumours  in  the  neck, 
if  they  are  to  be  removed,  ought  to  be  early  ex- 
tirpated, as  they  otherwise  plunge  deep,  and  form 
connexions  from  which  they  cannot  be  detached 


y /•«?  p9.WUt?U'l,{- 


-Plate  5.  p.89. 


OP  THE  HEAD  AND  NECK. 


121 


When  we  consider  the  absolute  necessity  there 
is  for  removing  the  whole  diseased  parts,  it 
becomes  evident,  that  unless  the  operation  be 
performed  early,  it  ought  to  be  prohibited. 
When  the  tumour  penetrates  deep  and  internal- 
ly it  cannot  be  completely  taken  away;  its  ad- 
hesions to  the  vessels  and  nerves  forbid  this;  and 
to  cut  into  it,  and  at  the  same  time  not  to  clear 
it  fairly  away,  is  to  irritate  and  extend  what  is 
left  behind. 

That  the  life  of  this  woman  might  have  been 
saved  in  the  early  stage  of  the  disease,  few  will 
doubt.  The  tumour  was  then  small,  its  adhe- 
sions were  limited,  and  to  parts  of  no  primary  im- 
portance. There  was  nothing  therefore  to  have 
prevented  its  removal.  To  reach  the  tumour, 
the  integuments,  platvsma  myoides  and  fascia, 
would  alone  have  required  to  have  been  divided, 
and  in  tearing  it  out,  the  upper  laryngeal  artery 
and  nerve,  would  have  been  the  only  parts  which 
to  a certainty,  would  have  been  injured.  Per- 
haps it  might  have  been  found,  that  from  the  firm 
fixture  of  the  morbid  parts  to  the  membrane  ex- 
tended from  the  os-hyoides,  to  the  thyroid  carti- 
lage, there  might  have  been  a necessity  for  cut- 
ting it  out  along  with  the  tumour.  But  even 
granting  that  an  opening  had  been  made  into  the 
fauces,  still  that  would  have  been  a matter  of  little 
consequence,  and  should  have  been  no  objection  to 
the  operation.  Under  much  worse  circumstances, 
16 


122 


ON  THE  SURGICAL  ANATOMY 


Desault  has  shewn  that  the  patient  may  be  nour- 
ished through  a flexible  tube,  passed  along  the 
nostril  into  the  oesophagus,  until  the  wound  has 
closed. 

These  points  were  reflected  on;  the  propriety 
of  submitting  to  the  extirpation  of  the  tumour, 
was  explained  to  the  patient,  who,  satisfied  of  the 
expediency  of  the  operation,  readily  gave  her 
consent  to  its  performance.  In  the  mean  time, 
she  consulted  a surgeon  in  whom  she  had  much 
confidence,  and  he,  without  inquiring  further  into 
the  merits  of  the  case,  than  merely  to  ascertain 
that  the  tumour  was  placed  in  the  neck,  informed 
her  that  she  ought  on  no  account  to  allow  its  ex- 
tirpation, that  the  danger  of  wounding  the  large 
vessels  and  nerves,  was  incalculable,  and  besides, 
that  there  was  a hope  that  the  swelling  might  be 
discussed.  She  delayed  from  day  to  day,  and 
from  week  to  week,  wasting  time  in  the  trial  of 
leeches,  and  blisters,  and  frictions  over  the  tu- 
mour; she  waited  in  the  vain  expectation  that 
these  means  would  lessen  the  swelling,  till  at 
length  she  became  convinced,  that  her  safety  had 
been  sacrificed  by  one  who  knew  little  of  the  re- 
sources of  surgery,  and  who  dreaded  the  opera- 
tion, merely  because  he  was  ignorant  of  the  rela- 
tions of  the  vessels  and  nerves.  Timidity  or 
rashness  must  be  the  attendant  of  ignorance, 
either  of  which,  in  our  profession,  is  highly  cul- 
pable. 


OF  THE  HEAD  AND  NECK. 


123 


It  was  most  distressing  to  witness  the  struggles 
for  breath,  and  the  cravings  for  food,  in  the  de- 
cline  of  this  woman’s  life;  yet  the  period  had 
passed,  when  it  was  advisable  that  any  attempt 
should  be  made  to  remove  the  tumour.  The  fea- 
tures were  haggard,  the  countenance  was  expres- 
sive of  keen  anxiety,  the  languid  eye  rolled  with 
out  ceasing,  from  object  to  object,  and  at  each 
gasp  the  muscles  about  the  neck  started  from 
their  place,  so  that  they  might  hare  been  demon- 
strated by  the  prominence  of  their  lines.  She 
was  now  eager  to  submit  to  any  operation,  but 
prudence  compelled  us  reluctantly  to  confess,  that 
palliation  was  all  that  surgery  could  now  accom- 
plish; we  were  under  the  mortifying  necessity  of 
declining  the  very  measure  we  had  recommended 
a few  months  before.  Let  this,  therefore,  be  a 
warning  to  all;  let  them  learn  from  this  case, 
never  to  give  an  opinion  on  any  surgical  question 
which  concerns  the  life  of  a patient,  till,  by  pre- 
vious study,  they  have  made  themselves  acquaint- 
ed with  the  structure  of  the  parts.  Let  them 
view  these  in  their  healthy  relations,  and  trace 
the  changes  produced  by  the  disease,  and  then 
they  may  reasonably  hope  to  give  a judicious 
opinion. 

In  the  middle  region  of  the  neck,  and  conse- 
quently at  a part  where  the  common  carotid  ar- 
tery is  merely  covered  by  the  skin,  platysma  mo- 
ides  and  fascia,  it  divides  into  two  vessels,  one 


124 


ON  THE  SURGICAL  ANATOMY 


large,  the  other  smaller;  one  distributed  to  the 
parts  within  the  skull,  the  other  ramified  on  the 
parts  exterior  to  it;  one  named  thence  the  exter- 
nal, the  other  called  the  internal  carotid  artery. 

In  regard  to  the  spot  where  the  common  carotid 
artery  divides  into  the  external  and  internal  ves- 
sels, there  is  no  certainty.  It  varies  in  different 
subjects  Mr.  Bell  says,  “when  the  common  ca- 
rotid artery  has  risen  to  the  angle  of  the  jaw,  it 
divides  into  two  great  arteries;”  and  again,  “in- 
stead of  branching  at  the  larynx,  it  does  not  do  so 
until  it  arrives  at  the  corner  of  the  jaw;  there,  as  I 
have  observed,  it  can  as  in  an  axilla,  lie  deep  and 
safe.”*  Even  in  the  adult,  however,  so  high  a 
division  is  a rare  occurrence,  and  in  the  child  it 
never  happens.  Generally,  in  both  the  young 
and  old  subject,  the  bifurcation  of  the  common 
parotid  artery  is  placed  opposite  to  the  upper 
margin  of  the  thyroid  cartilage.  But  in  fact,  the 
place  of  division  of  the  common  carotid  artery,  is 
liable  to  great  variety,  both  in  point  of  situation 
and  appearance.  Sometimes  it  bifurcates  low  in 
the  neck,  at  other  times  it  does  not  divide  at  all, 
but  merely  sends  off  branches  on  every  side;  and 
in  not  a few  instances,  a series  of  large  branches 
are  found,  in  place  of  an  external  carotid.  In  one 
of  our  subjects,  the  common  carotid  separated  into 
its  two  trunks  low  in  the  neck.  The  division  took 


* liell's  Anatomy,  vol.  2. 


OF  THE  HEAD  AND  NECK. 


125 


place  opposite  to  the  upper  edge  of  the  sixth  cer- 
vical vertebra,  and  about  three  inches  below  the 
angle  of  the  jaw.  The  two  vessels  mounted  along 
the  side  of  the  larynx  parallel  to  each  other,  and 
enveloped  in  the  same  sheath  with  the  internal 
jugular  vein  and  nervus  vagus. 

In  a preparation  of  the  vessels  of  the  head  and 
neck  which  is  in  my  possession,  the  external  ca- 
rotid is  a short  thick  stump,  resembling  the  axis 
arterise  cceliacse,  and  like  it  from  the  top  of  this, 
the  large  branches  take  their  origin.  This  mode 
of  arrangement  constitutes  a very  beautiful  va- 
riety in  the  appearance  of  the  vessels.  As  the 
parts  on  which  they  are  to  be  distributed,  lie 
above,  and  on  every  side,  the  branches  in  their 
course  to  these,  form  a very  fine  vascular  fan. 

In  another  preparation  which  was  also  in  my 
possession,  the  common  carotid,  instead  of  di- 
viding in  the  neck,  sent  off  lateral  branches,  till 
it  reaches  considerably  beyond  the  angle  of  the 
jaw.  Opposite  to  the  root  of  the  styloid  process, 
it  divided  into  two  branches,  one  formed  the  inter- 
nal carotid,  the  other  was  the  conjoined  trunk  of 
the  temporal  and  internal  maxillary  arteries. 

In  operating  about  the  neck,  it  is  necessary  to 
be  aware  of  these  varieties  in  the  course  and  ar- 
rangement of  its  vessels,  otherwise,  an  operator 
may  feel  himself  considerably  puzzled.  Nor  is  it 
sufficient  that  he  remembers  the  anomalies  of  these 
vessels,  he  must  also  make  himself  acquainted  with 


126 


ON  THE  SURGICAL  ANATOMY 


the  general  situation  of  the  external  and  internal 
carotid  arteries.  He  must  be  aware  that  the  ex- 
ternal carotid  lies  nearer  the  surface  and  closer 
to  the  pharynx,  than  the  internal;  consequently, 
that  the  former  is  considerably  removed  from  the 
nerves  and  large  vein.  It  is,  therefore,  much  ea- 
sier to  pass  a ligature  round  the  external  carotid 
artery,  than  round  either  the  internal  or  the  com- 
mon carotid.  Both  of  the  latter  are  in  absolute 
contact  with  the  large  nerves,  and  internal  jugular 
vein. 

The  necessity  of  cutting  down,  by  a deliberate 
dissection  on  the  carotid  artery,  and  passing  a 
ligature  round  it,  is  now  no  longer  a matter  of  spe- 
culation. The  surgeon  no  longer  hesitates  to  per- 
form this  operation,  because  he  is  well  aware  that 
the  danger,  although  great,  is  not  sufficient  to  de- 
ter him.  But  the  operation  is  truly  a bold  one. 
The  artery  is  of  large  size,  is  entangled  among 
important  nerves,  and  is  attached  by  cellular  mem- 
brane to  the  great  vein  which  returns  the  blood 
from  the  brain;  without,  therefore,  great  care  and 
delicacy  in  dissection,  it  can  hardly  be  taken  up 
without  injuring  either  the  vein  or  nerves.  These 
occasion  embarrassments  while  dissecting  down 
to  the  artery,  which  are  felt  by  even  the  most 
expert  surgeon,  and  most  accurate  anatomist; 
but  how  much  these  must  be  increased  when  all 
the  parts  are  covered  with  blood,  and  the  patient 
struggling  from  pain,  can  only  be  appreciated  by 


OF  THE  HEAD  AND  NECK. 


127 


those  who  have  been  in  the  habit  of  seeing  opera- 
tions performed. 

As  we  are  interested  not  only  in  the  consi- 
deration of  the  local  anatomy  of  the  neck,  and 
in  deducing  from  our  acquaintance  with  the 
structure,  the  proper  mode  of  operating;  but  are 
also  concerned  in  obtaining  just  and  compre- 
hensive views  of  the  general  principles  which 
ought  to  direct  our  practice,  it  cannot  be  sup- 
posed foreign  to  the  object  of  this  book,  to  in- 
vestigate the  general  causes  which  have  a ten- 
dency to  occasion  failure  of  the  operation  for 
the  cure  of  aneurism.  These  general  causes 
must  be  thoroughly  known  in  order  to  be  avoid- 
ed. The  discussion  of  these  points  will  lead  to 
the  illustration  of  those  circumstances  which  in- 
fluence the  success  of  the  operation  for  carotid 
aneurism. 

Compression  is  the  principle  and  foundation  of 
every  plan  which  has  been  adopted  for  the  cure 
of  aneurism.  The  only  difference  consists  in  the 
mode  of  applying  the  pressure.  General  com- 
pressions was  the  first  plan  employed,  but  its  de- 
fects were  discovered,  and  another  mode  intro- 
duced. The  artery  was  exposed  by  incision,  and 
the  pressure  applied  directly  to  the  vessei  itself. 
Each  of  these  plans  has  had  its  advocates  and  op- 
ponents; and  each,  it  must  be  confessed,  has  suc- 
ceeded in  accomplishing  a cure.  Now,  that  our 
knowledge  of  the  animal  economy  is  more  extend- 


128 


ON  THE  SURGICAL  ANATOMY 


ed  and  correct,  we  can  better  appreciate  the  rela- 
tive merit  of  these  modes,  which,  as  practised  by 
our  ancestors,  were  extremely  defective.  In  their 
hands  they  were  employed  on  empirical  princi- 
ples. At  first  sight,  it  is  apparent,  that  the 
same  plan  of  treatment  could  not  reasonably  be 
expected  to  answer  in  every  case;  nevertheless, 
however  varied  the  nature  of  the  tumour,  still 
the  plan  pursued  by  our  forefathers  was  iden- 
tically the  same.  No  matter  whether  the  tu- 
mour was  large,  tense,  painful  and  discoloured 
on  the  surface,  or  small  and  hard,  and  beating 
furiously;  the  bandage  and  compression  were  em- 
ployed, and  rules  were  prescribed  for  the  pre- 
vention of  gangrene. 

I cannot,  however,  discover  much  use  in  tra- 
cing, with  antiquarian  minuteness,  the  practices 
of  past  ages  which  are  long  since  forgotten,  or, 
if  still  remembered,  remembered  only  as  a foil  to 
our  modern  improvements.  No  doubt,  it  is 
highly  advantageous  to  the  younger  part  of  the 
profession,  that  the  progress  of  improvement 
should  be  pointed  out,  and  the  more  especially 
where  such  improvement  has  been  owing  to  ad- 
vancement in  anatomical  and  physiological  know- 
ledge. In  this  point  of  view,  a historical  ac- 
count of  the  operations  of  surgery  is  highly  va- 
luable, for  it  impresses  on  the  mind  an  impor- 
tant fact,  and  shews  that  the  practice  of  our  art 
is  not  to  be  fixed  on  firm  and  immutable  princi- 


OF  THE  HEAD  AND  NECK. 


129 


pies,  unless  these  be  deduced  from  a compre- 
hensive acquaintance  with  the  structure  and 
functions  of  the  living  system.  If  this  primary 
object  be  kept  in  recollection;  and  if,  in  proceed- 
ing it  be  fairly  stated  why  the  different  modes 
were  introduced,  no  one  can  possibly  object  to 
a review  of  the  practices  of  antiquity.  But  what, 
I would  inquire,  is  to  be  gained  by  the  usual  his- 
tories of  surgery,  which  are  seldom  more  than 
mere  notifications;— -that  Celsus  did  one  thing; 
Galen  another;  and  Etius  a third.  In  aneu- 
rism the  truth  of  this  has  been  most  amply  prov- 
ed. It  may  be  asked,  was  there  from  remote  an- 
tiquity down  to  Hunter,  a single  addition  made  to 
our  practical  knowledge  on  the  subject  of  aneu- 
rism? Was  this  dependent  on  want  of  anatomi- 
cal information?  Without  doubt  this  was  partly 
the  cause;  but  I think  it  chiefly  arose  from  indo- 
lence and  want  of  inclination  to  collect,  arrange, 
and  deduce  the  proper  practical  conclusions,  from 
the  data  in  their  possession.  Was  it  not  known, 
previous  to  the  time  of  Hunter,  that  the  vessel  in 
the  immediate  vicinity  of  an  aneurism  was  gene- 
rally diseased?  And  was  it  not  also  fully  proved 
that  after  a wound  of  a healthy  artery,  the  ves- 
sel, if  included  in  a ligature,  became  obliterated? 
It  did  not,  one  would  imagine,  require  the  genius 
of  a Hunter  to  draw  the  proper  inference  from 
these  facts;  yet  it  was  left  for  him  to  do  so.  He 
improved  the  operation,  he  laid  the  foundation  of 
17 


130 


ON  THE  SURGICAL  ANATOMY 


our  practice:  but  to  Drs.  Thomson,  Jones,  and 
Scarpa,  we  are  deeply  indebted  for  our  present 
success. 

In  tracing  the  history  of  this  operation,  I shall, 
in  the  first  place,  notice  the  mode  of  cure  by  ge- 
neral eompresssion  of  the  member,  pointing  out 
the  advantages  and  defects  of  this  plan;  next,  the 
cure  by  ligature  of  the  vessel,  which  is  alone  to 
he  employed  in  carotid  aneurism,  shall  he  attend- 
ed to;  the  causes  will  be  shewn  why  this  plan,  at 
its  introduction,  seldom  succeeded;  and  the  pro- 
gressive improvement  in  the  mode  of  using  the 
ligature,  which  has  arisen  from  our  extended 
knowledge  of  the  structure  and  relations  of  the 
coats  of  the  arteries,  shall  be  explained. 

Previous  to  the  introduction  into  use  of  the 
ligature,  general  compression  was,  along  with 
trivial  external  applications  to  the  tumour,  en- 
tirely trusted  to.  Nor  are  cases  wanting,  in 
which  the  compression  was  successfully  employ- 
ed. At  the  present  day,  some  recommend  its  in- 
discriminate use  in  every  instance,  while  others 
are  equally  decided  that  it  should  be  employed  in 
no  case.  Those  who  adopt  the  practice,  or  who 
reject  its  employment,  ought  to  he  acquainted 
with  the  principles  on  which  they  proceed;  but 
few  who  are  thus  decided  act  on  any  principle  ex- 
cept that  of  imitation.  Experience  proves  that 
there  are  cases  in  which  general  compression 
may  be  most  beneficially  used;  but  it,  at  the 


OF  THE  HEAD  AND  NECK. 


131 


same  time,  informs  us,  that  there  are  others  in 
which  it  would  be  most  injurious.  What  then 
are  the  cases  in  which  general  compression  is  ad- 
visable, and  what  the  reverse?  One  who  is  ac- 
quainted with  the  mode  by  which  a spontaneous 
cure  is  effected,  will  be  at  no  loss  to  answer 
this  question.  He  will  know  that  whenever  the 
symptoms  are  such  as  to  indicate  a tendency  to 
spontaneous  cure,  compression  will  assist  in  com- 
pleting it.  Thus,  when  the  tumour,  at  the  same 
time  that  it  is  large  and  firm,  and  not  beating 
strongly,  is  neither  painful  nor  discoloured,  gene- 
ral compression,  judiciously  employed,  will  prove 
a most  beneficial  auxiliary  in  the  cure.  Nay, 
even  where  the  aneurism  is  only  in  its  incipient 
stage,  general  compression,  although  it  will  not  be 
so  certainly  successful,  is  not  without  its  advanta- 
ges. Indeed,  it  never  does  harm,  if  not  produc- 
tive of  much  pain,  which,  along  with  an  increase 
of  numbness,  ought  to  be  considered  as  monitors 
to  desist.  It  need  hardly  be  observed,  that  where 
the  swelling  is  inflamed,  painful,  and  diffused, 
its  use  can  never  be  permitted,  it  would,  if  em- 
ployed in  such  circumstances,  aggravate  the  dis- 
ease it  was  meant  to  cure. 

In  using  general  compression,  our  intention 
is  in  no  case  to  induce  or  increase  inflammation, 
which  would,  almost  to  a certainty,  terminate  in 
gangrene.  On  the  contrary,  the  object  we  hold 
in  view  is  to  produce  coagulation  of  the  blood 


132 


ON  THE  SURGICAL  ANATOMY 


in  the  sac,  and  thus  to  cut  off  the  aneurismal 
cyst  from  any  share  in  the  circulation.  If  this  be 
accomplished,  the  absorbents  will  soon  perform 
their  part  of  the  process.  They  will  slowly 
remove  both  the  sac  and  its  contents,  leaving,  in 
the  end,  in  the  place  where  the  tumour  had  been, 
a small,  generally  oblong,  hard  knot,  free  of  pul- 
sation. 

Compression,  however,  to  be  useful,  must  be 
prudently  applied,  and  skilfully  managed.  The 
mode  employed  by  some,  of  merely  fixing  a firm 
compress  and  tight  roller  over  the  tumour,  de- 
serves the  strongest  reprobation.  It  is  unscien- 
tific, and  besides,  exceedingly  injurious.  Con- 
sider that  pressure  employed  in  this  way  is  infi- 
nitely more  painful  than  even  the  operation,  that 
it  is  completely  ineffectual;  and  uniformly,  if 
persisted  in,  is  productive  of  disagreeable  conse- 
quences; and  few,  I am  persuaded,  will  be  in- 
clined to  risk  its  use.  If  the  compression,  when 
it  is  thus  partially  employed,  be  carried  to  that 
extent  which  would  be  required  to  affect  the 
tumour  or  the  artery,  the  functions  of  the  veins, 
nerves,  and  absorbents,  must  suffer.  The  veins 
and  lymphatics  will  soon  be  distended,  oedema 
will  supervene,  the  limb  below  the  point  of  com- 
pression will  swell,  and  be  rendered  torpid  from 
the  pressure  on  its  nerves;  it  will  narrowly  escape 
falling  into  gangrene.  Is  this  a condition  which 
one  would  suppose  conducive  to  the  establish- 


133 


OF  THE  HEAD  AND  NECK. 

ment  of  a new  course  for  the  circul  tion?  Or  can 
we  reasonably  entertain  a hope,  that  in  this  situ- 
ation the  anastomosing  vessels  shall  regularly  dis- 
charge their  duty? — Surely  not. — Pressure  used 
in  a partial  manner,  never  can  do  good,  but 
will  often  do  much  harm.  Let  it,  therefore,  be 
abandoned;  for  discredit  has,  I believe,  been 
brought  on  the  mode  of  cure,  by  general  com- 
pression, merely  from  the  injudicious  way  in  whi  h 
it  has  been  employed,  or  from  making  use  of  it  in 
improper  cases. 

It  has  already  been  mentioned,  that  if  the  tu- 
mour be  circumscribed,  the  surface  not  discoloured, 
and  the  parts  not  painful  nor  tender  when  touched, 
we  may,  even  although  general  compression  will 
not  accomplish  a cure,  gain  some  advantage  from 
using  it.  We  are  next  to  inquire  how  it  is  to  be 
em  ployed. 

When  general  compression  is  to  be  employed, 
we  begin  by  applying  the  roller  in  the  usual  way 
to  the  extremity  of  the  member,  and  we  continue 
it  of  equal  tightness  up  to  the  lower  part  of  the 
tumour.  When  we  have  thus  far  applied  it,  we 
place  a compress  over  the  swelling,  and  over  this 
we  apply  the  bandage,  encircling  the  member  up 
to  the  joint  above  where  the  disease  is  seated,  but 
pulling  it  less  tightly  the  higher  we  go.  This  is 
really  all  that  is  required,  although  some  advise 
the  affusion  of  vinegar  and  water,  or  of  medicated 
waters  over  the  bandage  and  compress.  These 


134 


ON  THE  SURGICAL  ANATOMY 


we  never,  however,  require,  unless  where  the  sur- 
face, from  the  continuance  of  the  pressure,  be- 
comes fretted.  This  is  not  an  unfrequent  occur- 
rence, neither  is  it  very  prejudicial,  except  where 
it  is  conjoined  with  deep-seated  acute  pain  in  the 
tumour,  and  increased  numbness  of  the  parts  be- 
low the  swelling;  in  which  case,  the  compression 
must  be  laid  aside. 

The  great  difficulty  of  obtaining  a cure  by  ge- 
neral compression,  arises  from  the  length  of  time 
it  is  absolutely  necessary  to  continue  its  use,  and 
the  privations  to  which  the  patient  must  submit 
during  the  cure.  Even  where  the  tumour  de- 
creases under  its  use,  nay,  where  it  has  even  be- 
come as  small  as  a bean,  and  has  ceased  to  pulsate, 
the  bandage,  to  insure  success,  must  be  continued 
for  weeks,  during  which  time  the  patient  must  re- 
frain from  active  exertion  with  the  affected  member, 
must  be  placed  on  a rigid  antiphlogistic  regimen, 
and  must  submit  to  bleeding  and  purging  at  short 
intervals.  This  catalogue  will  be  sufficient  to  de- 
ter most  patients  from  submitting  to  this  mode; 
none  but  those  who  are  too  timid  to  undergo  an 
operation,  will  choose  to  endure  the  protracted 
hardships  of  this  discipline;  and  few,  even  after 
they  have  given  their  consent,  will  have  sufficient 
perseverance  to  proceed.  From  these  and  other 
causes  which  have  already  been  hinted  at,  we 
shall  not  be  surprised,  that  comparatively,  few 


OF  THE  HEAD  AND  NECK. 


135 


cures  are  on  record  effected  by  general  compres- 
sion. 

When  the  ligature  was  first  introduced  in  the 
treatment  of  aneurism,  the  practice  was  conducted 
without  principle;  it  was  founded  on  a combina- 
tion of  experience  and  mechanical  reasoning,  and 
employed  altogether  without  any  regard  to  the 
causes  which  would  insure  its  success,  or  occasion 
its  failure.  The  mode  even  of  performing  this 
operation,  was  at  first  rude  and  defective;  nor 
when  it  began  to  be  improved,  was  the  progress 
of  amendment  by  any  means  rapid.  Instead  of 
viewing  the  operation  in  all  its  relations,  and  de- 
tecting and  correcting,  at  once,  all  the  improprie- 
ties in  its  performance,  each  inquirer  merely  ad- 
ded a little  to  the  information  collected  before  his 
time.  This  slowness  in  improvement,  in  a great 
measure,  depended  on  overlooking  the  connexions 
and  relations  of  the  arteries  to  the  neighbouring 
parts  in  a state  of  health;  and  especially  to  sur- 
geons having  obtained  no  precise  ideas,  respecting 
the  way  in  which  the  coats  of  the  vessels  them- 
selves are  nourished.  We  shall,  in  tracing  the 
progress  of  the  ligature,  see  many  proofs  of  the 
operator,  for  want  of  this  knowledge,  having  de- 
feated the  very  end  he  had  in  view. 

Surgeons,  till  lately,  considered  the  application 
of  a ligature  to  an  artery,  as  a mere  mechanical, 
and  consequently  a very  simple  operation;  but  the 
experiments  of  modern  physiologists  have  clearly 


136  ON  THE  SURGICAL  ANATOMY 


proved  that  the  operation  for  aneurism,  is  one  of 
the  nicest  in  surgery,  involving  in  its  performance, 
the  combination  of  accurate  anatomical  and  physi- 
ological information.  Let  no  one,  therefore,  at- 
tempt its  execution,  till  he  has,  by  diligent  study, 
made  himself  thoroughly  acquainted  with  all  the 
facts  which  are  to  regulate  his  conduct.  Let  him 
not  consider  it  enough  that  he  can  safely  cut  down 
to  an  artery,  and  pass  a thread  round  it,  for  this 
the  ancients  could  do  as  dexterously  as  most  of  the 
moderns;  yet  the  records  of  surgery  shew,  that  in 
this  very  operation,  the  early  performers  of  it 
much  oftener  failed  than  we  do.  The  reason  of 
this  difference  will  be  best  explained,  and  easiest 
understood,  if  the  effects  resulting  from  the  appli- 
cation of  a ligature  to  an  artery,  and  the  causes  of 
secondary  haemorrhage,  be  first  pointed  out. 

Dr.  Jones,  who  has  written  a most  able  treatise 
on  these  subjects,  conceives  that  the  first  effect 
produced  by  the  ligature,  is  a division  of  the  two 
internal  coats  of  the  artery,  by  which  such  a de- 
gree of  inflammation  is  brought  on,  as  must  be 
followed  by  the  effusion  of  organized  lymph  be- 
tween the  coat  of  the  artery  and  around  it.  Some- 
times, but  not  uniformly,  a clot  of  blood  is  formed 
in  the  canal  of  the  vessel  above  the  thread,  "But 
the  formation  of  this  coagulum  is  of  little  conse- 
quence; for  soon  after  the  application  of  the  liga- 
ture, the  extremity  of  the  artery  begins  to  eu- 
flame;  and  the  wounded  internal  surface  of  its 


OF  THE  HEAD  AND  NECK.  137 

canal  being  kept  in  close  contact  by  the  ligature, 
adheres  and  converts  this  portion  of  the  artery  into 
an  impervious,  and  at  first,  slightly  conical  sac.”* 
“After  a short  time,  the  ligature  occasions  ulce- 
ration of  the  part  around  which  it  is  immediately 
applied;  and  acting  as  a tent,  a small  aperture  is 
formed  in  the  layer  of  lymph,  effused  over  the 
artery;  through  this  aperture  a small  quantity  of 
pus  is  discharged,  so  long  as  the  ligature  remains; 
and  finally,  the  ligature  itself  also  escapes,  and 
the  little  cavity  which  it  has  occasioned,  granu- 
lates and  fills  up,  and  the  external  wound  heals 
in  the  usual  manner,  leaving  a considerable 
thickening  and  induration  of  the  cellular  mem- 
brane, extending  a little  beyond  the  extremity  of 
the  artery. This  thickening  and  induration 
gradually  disappears.  “The  portion  of  the  arte- 
rial trunk  which  has  been  tied,  undergoes  a 
gradual  contraction  and  obliteration  to  the  first 
collateral  branches,  and  finally  dwindles  to  a 
mere  fibre. 

“The  collateral  branches  are  unusually  dis- 
tended, and  excited  to  stronger  action,  from  the 
moment  that  a complete  obstruction  is  formed  in 
the  trunk,  and  consequently  the  commencement 
of  their  enlargement  may  be  referred  to  that 
period.  Their  increase  of  size  seems  to  be  pro- 
portioned to  the  exigence  of  the  particular  case; 


* Jones,  p.  169, 

18 


t Jones,  p.  16J. 


138  ON  THE  SURGICAL  ANATOMY 


thus,  if  the  limb  has  been  amputated,  it  does  not 
appear  to  be  very  considerable;  but  if  the  limb 
remain  entire,  and  only  the  natural  course  of  the 
circulation  be  obstructed  through  the  main  arte- 
rial trunk,  their  enlargement  is  much  more  conspi- 
cuous, and  is  particularly  observable  in  the  small 
inosculating  ramifications  of  the  collateral  branches, 
by  which  the  circulation  appears  to  be  carried  on, 
after  a certain  time,  as  vigorously  in  the  limb, 
the  principal  artery  of  which  has  been  obstructed, 
as  in  that  which  has  preserved  its  circulation. 

“The  effects  of  tying  an  artery  properly,  ap- 
pear then  to  be  the  following: — 

“1st.  To  cut  through  the  internal  and  middle 
coats  of  the  artery,  and  to  bring  the  wounded  sur- 
face into  perfect  apposition. 

“2dly,  To  occasion  a determination  of  blood 
on  the  collateral  branches. 

“3dly,  To  allow  of  the  formation  of  a coa- 
gulum  of  blood  just  within  the  artery,  provided 
a collateral  branch  is  not  very  near  the  ligature. 

“4thly,  To  excite  inflammation  in  the  internal 
and  middle  coats  of  the  artery,  by  having  cut 
them  through,  and  consequently,  to  give  rise  to 
an  effusion  of  lymph,  by  which  the  wounded  sur- 
faces are  united,  and  the  canal  is  rendered  imper- 
vious; to  produce  a simultaneous  inflammation  on 
the  corresponding  external  surface  of  the  artery, 
by  which  it  becomes  very  much  thickened  with 
effused  lymph;  and  at  the  same  time,  from  the 


OF  THE  HEAD  AND  NECK 


139 


exposure  and  inevitable  wounding  of  the  sur- 
rounding parts,  to  occasion  inflammation  in  them, 
and  an  effusion  of  lymph  which  covers  the  artery, 
and  forms  the  surface  of  the  wound. 

“5thly,  To  produce  ulceration  in  the  part  of 
the  artery  around  which  the  ligature  is  immedi- 
ately applied,  viz.  its  external  coat. 

“6thly,  To  produce  indirectly  a complete  obli- 
teration, not  only  of  the  canal  of  the  artery,  but 
even  of  the  artery  itself  to  the  collateral  branches, 
on  both  sides  of  the  part  which  has  been  tied. 

“7thly,  To  give  rise  to  an  enlargement  of  the 
collateral  branches.7’* 

The  celebrated  Desault  had  observed  many 
years  ago,  that  on  tying  a ligature  pretty  firmly 
round  an  artery,  the  “tissu  arterieV 7 and  internal 
coat  were  both  cut.f  The  same  fact  was  also 

* Jones,  pages  163,etseq. 

f It  may,  perhaps  to  some,  be  necessary  to  explain  what  is  meant  by 
“tissu  arteriel .”  By  dissection,  an  artery  may  be  shewn  to  consist  of  lour 
coats.  The  internal  is  membranous  and  highly  polished;  the  next  is 
firm  and  fibrous; — the  third  is  membranous, — and  the  fourth  or  outermost, 
is  loose  and  shaggy.  In  describing  the  structure  of  an  artery,  Dr.  Jones 
divides  the  coats  into  an  internal,  middle,  and  external,  describing  in  this 
•way,  the  membranous  and  shaggy  coats,  as  forming  parts  of  the  external 
coat. 

The  outermost  coat  is  composed  of  thin  plates,  attached  to  each  other  by 
shining  filaments;  by  these  it  is  likewise  connected  to  the  neighbouring 
parts.  This  coat,  which  is  shaggy,  extremely  loose,  and  composed  of 
cells,  containing  in  the  young  animal,  a serous  fluid,  but  in  those  advanced 
in  life  an  oily  matter,  i3  really  the  cellular  coat  of  an  artery.  This  coat  is 
peculiarly  adapted  for  facilitating  the  motions  of  the  vessel,  and  for  con- 
veying to  the  deeper-seated  coats,  those  little  arteries  which  are  to  nourish 
them. 

The  coat  next  to  the  cellular  is  firm,  compact,  filamentous,  and  so  dense, 


140 


ON  THE  SURGICAL  ANATOMY 


pointed  out  by  Dr.  Thompson,  and  by  Bichat, 
who  observes,  “on  peut  l’observer,  en  liant  un  peu 
fortement  une  artere  les  deux  tuniques  internes 
sont  coupees:  la  celluleure  seule  soutient  Feffort 
de  la  ligature,  qui  cependant  lui  est  immediate- 
ment  appliqiwe;  on  observe  en  ouverant  l’artere 
une  section  correspondente  au  fil,  exactment 
semblable  a celle  qu'auroit  faite  un  instrument 
tranchant. 

“J’ai  repete  souvent  cette  experience,  indiqu^e 

that  it  was  named  by  Vesalius  the  membranous,  and  by  Senac,  the  ten- 
dinous coat.  It  is  truly  of  a membranous  structure,  and  is  so  strong,  that 
a force  which  lacerates  the  coats  beneath,  makes  little  impression  on  it. 
On  this  coat  an  artery  chiefly  depends  for  its  longitudinal  strength.  By 
its  elasticity,  it  serves,  as  Dr.  Jones  very  justly  remarks,  in  some  respects, 
the  purpose  of  a strong  fascia. 

The  third  coat,  or  “Le  tissu  arteriel ” of  Bichat,  consists  of  many  strata 
or  layers,  which  can  he  separated  from  each  other,  and  which  are  found 
to  be  composed  of  circular  fibres. 

These  fibres  vary  in  their  colour  in  different  subjects,  and  at  different 
periods  of  life.  In  young  subjects,  pale  red  fibres  predominate,  but  in 
aged  bodies,  those  of  a yellowish  colour  are  most  numerous.  The  ‘-tissu 
arteriel'''  is  a texture  peculiar  to  arteries,  there  being  nothing  similar  to  it 
found  in  any  other  part  of  the  body. 

The  internal  coat  is  very  thin,  transparent,  and  entirely  without  dis- 
tinction of  fibres.  On  its  inner  surface  it  is  highly  polished;  hut  on  its  outer 
surface,  it  is  less  smooth,  being  connected  by  pellucid  fibres  to  the  -tissu 
arterial,-"  yet  the  union  is  so  very  slight,  that  these  coats  can  be  easily  de- 
tached from  each  other,  without  perceptible  laceration  of  the  proper  tex- 
ture of  either.  Along  its  whole  extent,  this  coal  is  elastic,  and  in  the  lon- 
gitudinal direction,  stronger  than  we  would  suppose;  but  it  is  “so  w eak  in 
the  circular,  as  to  be  very  easily  torn  by  the  slightest  force  applied  in  that 
direction.  ”* 

lx  either  the  tissu  arteriel,  nor  the  internal  coat  have  any  cellular  texture 
entering  into  their  composition. 

* Jones,  page  1. 


OF  THE  HEAD  AND  NECK. 


141 


par  Desault  soit  sur  le  cadavere,  soit  sur  les  ani- 
maux  vivens;  son  resultat  est  fort  constant.”* 
From  this  fact  and  his  own  experiments,  Dr. 
Jones  has  been  led  to  consider  the  division  of  these 
coats  by  the  ligature,  an  essential  part  in  the  ope- 
ration, one  without  which  obliteration  would  not 
take  place.  By  many  it  will  be  considered  pre- 
sumptuous in  me  to  attempt  a refutation  of  this 
conclusion:  yet  I cannot,  to  my  own  satisfaction, 
reconcile  this  doctrine  with  facts  which  we  have 
daily  an  opportunity  of  observing.  Do  we  not 
every  day  see  the  whole  tract  of  the  umbilical  ar- 
tery, from  the  side  of  the  bladder  to  the  navel,  ob- 
literated? Now,  what  produces  this  obliteration. 
Some  may  reply,  the  ligature  tied  round  the  chord 
in  the  human  subject,  or  the  gnawing  of  the  chord 
in  the  lower  animals;  but  does  this  explanation 
apply  to  the  ductus  arteriosus? — Surely  not.  Oth- 
ers may  assert,  that  it  is  wisely  provided  by  na- 
ture, that  these  vessels  when  they  cease  to  be  use- 
ful, should  be  obliterated;  but  this  explains  no- 
thing, our  wish  is  to  learn  how  they  are  oblite- 
rated. We  trace  the  same  smooth  and  shining 
membrane  along  them  as  along  other  parts  of  the 
vascular  system;  yet  we  see  that  without  division 
of  this,  the  ductus  arteriosus  is  almost  uniformly 
converted  into  an  impervious  and  ligamentous- 
looking  chord.  What  is  there  to  prevent  the 
same  from  taking  place  in  other  arteries? 


* Bichat  Anatomie  Generate,  tome  2d.  p.  181  et  seq. 


142  ON  THE  SURGICAL  ANATOMY 


Some  speculation  has,  I suspect,  crept  into  the 
reasoning  of  Dr.  Jones  on  this  point,  and  this  has, 
I suppose,  led  him  to  the  inference,  that  division 
of  the  two  internal  coats  is  absolutely  required  to 
procure  obliteration.  To  me  it  does  not  appear 
that  his  facts  warrant  this  conclusion;  they  rather 
seem  to  shew  that  division  of  these  coats  does  not 
prevent  obliteration,  than  that  it  assists  in  com- 
pleting the  process.  At  all  events,  the  oblitera- 
tion of  the  ductus  arteriosus,  proves  that  adhe- 
sion of  the  sides  of  an  artery  does  take  place, 
without  division  of  its  internal  coats.  This  is 
corroborated  by  observations  made  on  external 
vessels.  I have  in  my  possession  a preparation, 
in  which  about  two  inches  of  the  common  and 
superficial  femoral  arteries  are  obliterated.  This 
extensive  obliteration  I discovered  accidentally, 
when  dissecting  the  limb  of  a man,  whose  leg  had 
been  amputated  above  the  knee  many  months 
before.  The  obstructed  part  was  seated  just 
about  the  spot  where  the  vessel  must  have  been 
pressed  on  by  the  tourniquet;  but  it  cannot  be 
determined  that  the  obliteration  was  produced  by 
the  compression  made  by  that  instrument.  It  has 
evidently  no  connexion  with  the  application  of  the 
ligature;  for  between  the  obliterated  portion  and 
the  part  acted  on  by  the  thread,  there  was  a 
considerable  extent  of  pervious  vessel,  into  which 
the  blood  was  conveyed  by  an  enlargement  of  the 
anastomosing  branches  of  the  posterior  pelvical 


OF  THE  HEAD  AND  NECK. 


143 


arteries.  In  the  humeral  artery  I likewise  found 
a similar  obliteration,  without  any  external  cica- 
trix, or  any  matting  of  the  parts  around  the  ves- 
sel, which  certainly  proved  that  the  obstruction 
had  not  been  produced  by  any  agent  directly 
acting  on  the  vessel  itself. 

From  the  almost  uniform  obliteration  of  the 
ductus  arteriosus  and  umbilical  arteries,  and  from 
the  occasional  cases  which  are  met  with,  similar 
to  those  mentioned  of  the  femoral  and  humeral 
arteries,  it  is  allowable  to  conclude,  that  without 
laceration  of  the  internal  coats,  adhesion  of  the 
sides  of  a vessel  may  be  procured,  provided  the 
flow  of  blood  along  its  canal  be  interrupted. 
This  will  be  accomplished  by  merely  keeping  the 
sides  of  the  artery  in  contact;  for  the  pressure 
required  to  do  this,  will,  generally,  if  the  vessel 
be  healthy,  excite  such  a degree  of  increased 
action,  as  will  end  in  the  effusion  of  organized 
lymph.  On  this  subject,  which  is  not  devoid  of 
practical  interest,  we  have  the  corroborative  tes- 
timony of  Bichat,  whose  observation  is  made 
without  any  reference  to  a particular  hypothesis, 
or  to  the  point  under  discussion.  His  remark  is, 
“Arteres  privees  de  sang  contractent  des  intimes 
adherences  par  leurs  surfaces  internes/’* 

Several  months  after  the  preceding  remarks 
were  written,  and  after  they  had  been  read  both 

* Bichat  Anat,  Gen.  tome  2d,  p.  291, 


144 


ON  THE  SURGICAL  ANATOMY 


by  ray  brother  and  by  Dr.  Brown,  Mr.  Charles 
Bell  published  the  third  edition  of  his  System  of 
Dissections.  Although  in  this  he  has  anticipated 
me,  I feel  much  pleasure  in  corroborating  what 
I have  written,  by  Mr.  Bell’s  observations.  This 
author  says,  “In  the  first  place  I deny  that  cut 
surfaces  adhere  more  readily  than  a natural  sur- 
face, in  a state  of  inflammation.  The  effect  of 
the  ligature  ought  to  be  inflammation  of  the 
coats  of  the  vessel,  and  the  preservation  of  the 
inner  surface  in  contact.  Much  as  I admire  the 
ingenuity  of  Mr.  Jones,  yet  an  experiment  has 
been  made  in  my  room,  which  throws  more  light 
on  the  subject  than  twenty  experiments  of  cut- 
ting the  artery.  A ligature  was  put  about  an  ar- 
tery quite  loose,  and  without  obstructing  the 
blood,  in  due  time  the  clot  was  formed,  and  the 
eoagulable  lymph  thrown  out,  and  the  artery  ob- 
structed. Yet,  from  fifty  such  experiments,  uni- 
formly successful,  it  would  be  madness  to  say, 
that  in  tying  an  aneurismal  artery  we  were  not  to 
draw  tight  the  ligature,  but  only  leave  it  there 
surrounding  and  causing  inflammation  of  the  ar- 
tery. I conceive  it  little  less  rational,  because 
cutting  the  inner  coats  of  an  artery  in  brutes,  is 
followed  by  the  closing  of  the  artery,  to  say,  that 
in  an  operation  of  aneurism  we  were  to  draw  the 
ligature  till  we  felt  the  giving  way  of  the  inner 
coats.”* 

* Kell’s  Dissections,,  third  edition,  vol.  1st,  pages  1-iO,  141. 


OF  THE  HEAD  AND  NECK. 


145 


The  conclusion  which  I have  drawn  from  the 
facts  before  me,  is  further  supported,  by  attend- 
ing to  the  effects  produced  by  ligature  of  an  ar- 
tery. It  is  not  only  the  part  cut  by  the  thread 
which  adheres.  The  truth  is,  we  really  find  the 
sides  of  the  artery  adhering  to  each  other,  up  to 
the  origin  of  the  first  lateral  branch,  although 
that  should  not  happen  to  come  off,  for  an  inch  or 
two  beyond  where  the  ligature  has  been  applied. 

Scarpa,  in  dissecting  the  artery  of  the  thigh 
after  amputation,  found  the  “tissu  arteriel ” thick- 
er than  usual,  and  the  internal  coat  of  a bright  red 
colour,  covered  for  a considerable  extent  by  a 
lymphatic  exudation;  on  removing  which,  the  coat 
itself  was  found  pulpy,  villous,  very  vascular,  and 
in  an  apt  state  for  adhesion.  Now,  if  the  inter- 
nal coat  can  undergo  these  changes,  and  adhere 
where  not  acted  on  by  the  thread,  it  is  certainly 
fair  to  suppose,  that  its  division  is  not  essen- 
tial in  procuring  the  obliteration.  This,  to  my 
apprehension,  is  fully  proved,  by  the  oblitera- 
tion of  the  canal  of  the  artery,  for  some  way  above 
and  below  the  sac,  in  cases  of  spontaneous  cure 
of  aneurism.  The  ligature,  I suppose,  does  no 
more  than  by  its  irritation,  excite  such  an  increas- 
ed action  in  the  vessel,  as  shall  occasion  the  se- 
cretion of  organized  lymph.  The  same  may  be 
done  by  bruising  it,  or  by  loosely  placing  a thread 
round  it. 

19 


14(5 


ON  THE  SURGICAL  ANATOMY 


There  is  a part  of  the  process  of  obliteration 
which  must  be  attended  to;  I mean  the  clot  of 
blood,  which  is  sometimes  formed  in  the  vessel. 
If  we  view  this  in  its  proper  light,  we  shall  have 
occasion  to  admire  the  office  it  performs.  Bichat 
has  shown,  that  naturally  no  absorption  goes  on 
from  the  inner  surface  of  arteries.  Nature  has, 
therefore,  increased  her  own  task,  by  forming  a 
bloody  clot.  Unless  it  performs  a part  in  the 
process,  its  presence  must  be  detrimental,  since  it 
must  be  removed  before  adhesion  can  take  place. 
Where  it  is  found,  such  a change  must  afterwards 
be  induced,  in  the  nature  of  the  internal  coat,  as 
shall  adapt  it  for  removing  by  absorption  the  ex- 
traneous substance.  The  accomplishment  of  this 
also  renders  the  aptitude  for  adhesion  greater. 

A coagulum,  as  we  learn  from  Dr.  Jones’  expe- 
riments, is  chiefly  formed  where  the  distance  from 
the  ligature  to  the  first  lateral  branch  is  consider- 
able. Where  the  distance  is  short,  the  ligature 
excites  a sufficient  degree  of  irritation  to  produce 
the  lymphatic  effusion;  but  where  it  is  considera- 
ble, that  part  in  the  vicinity  of  the  thread  is  suf- 
ficiently excited:  not  so  the  more  remote  part. 
From  the  natural  effect  of  the  stagnation  of  the 
blood,  a coagulum  is  formed,  which  being  an  ex- 
traneous substance,  excites  the  action  of  that  part 
of  the  canal  of  the  vessel  with  which  it  is  in  con- 
tact, procures  its  own  absorption,  and  at  the  same 
time  causes  an  effusion  of  organized  lymph.  This 


OF  THE  HEAD  AM(  NECK. 


147 


is  really  the  only  benefit  which  can  be  derived 
from  the  formation  of  a coagulum;  and  its  pres- 
ence, under  these  circumstances,  shews  that  all 
that  is  required  to  produce  obliteration,  is  a cer- 
tain degree  of  irritation,  applied  to  a healthy  ar- 
tery. If  this  be  brought  about,  the  adhesion  will 
be  complete. 

When  we  examine  an  artery  a considerable  time 
after  it  has  become  obliterated,  the  “iissu  arteriel ” 
is  found,  as  well  as  the  lymph,  which  was  origi- 
nally effused  between  the  coats  and  round  the 
vessel,  to  be  completely  removed  by  absorption. 
The  obliterated  portion  is  converted  into  a liga- 
mentous looking  chord,  composed  of  longitudinal 
fibres,  among  which  we  cannot  discern  a single 
circular  fibre.  By  care,  we  can  generally,  for  a 
short  way  along  the  impervious  chord,  trace  the 
internal  coat,  shrunk  indeed,  and  thinner  than 
before. 

Frequently  the  ligature  fails  to  produce  the  de- 
sired effect.  In  place  of  inducing  healthy  ac- 
tions, tending  by  their  combination,  to  produce 
obliteration  of  the  canal  of  the  artery,  it  acts  as 
an  exciter  of  disease,  which  defeats  the  end  of 
operation.  No  point  is  more  worthy  of  being  fully 
investigated,  than  the  causes  giving  rise  to  se- 
condary haemorrhage;  and  there  is  no  department 
of  surgery,  in  which  we  have  to  acknowledge 
more  obligation  to  any  individual,  than  we  have 
in  this  to  Dr.  Jones.  Indeed  he  has  so  ably  pro- 


148 


ON  THE  SURGICAL  ANATOMY 


secuted  this  inquiry,  that  he  has  left  but  little  for 
any  of  his  successors  to  add  to  his  information. 

This  author  justly  observes,  that  our  object  is 
to  heal  by  the  first  intention;  he  applies  the  liga- 
ture for  the  express  purpose,  as  he  says,  of  wound- 
ing as  with  a clean  cut,  the  internal  coats  of  the 
vessel.  This,  in  his  estimation,  is  the  primary 
object  in  using  the  ligature;  the  secondary,  is  to 
preserve  the  edges  of  the  wound  in  accurate  con- 
tact. Having  set  out  with  this  principle,  he  pro- 
ceeds to  the  enumeration  of  the  circumstances, 
rendering  the  ligature  a preventive  of  union  by 
the  first  intention.  The  first  he  mentions,  is  an 
irregularity  in  the  form  of  the  ligature,  by  which 
it  acts  more  on  one  part,  than  on  another,  where- 
as, to  produce  the  proper  effect,  the  internal  coats 
ought,  in  his  opinion,  to  be  regularly,  fully,  and 
equally  divided.  ‘•Although  the  internal  surface 
of  the  artery  appeared  inflamed,  a little  way 
above  the  part  at  which  it  adhered,  yet,  in  no  in- 
stance did  it  exhibit  the  appearance  of  lymph 
having  been  effused  on  it,  except  at  the  part  which 
had  been  cut,  and  the  point  of  adhesion  was  ne- 
ver more  than  a line’s  breadth;  in  short,  the  ar- 
tery seemed  to  adhere  only  at  its  cut  surfaces. "* 
How  is  this  to  be  reconciled  with  Scarpa's  dissec- 
tion of  the  femoral  artery,  formerly  noticed?  and 
liow,  with  the  well  established  fact,  that  the  canal 


* Jones,  page  169. 


OF  THE  HEAD  AND  NECK. 


149 


of  the  vessel  is  obliterated  much  above  the  liga- 
ture? 

There  are  many  circumstances  which  would 
lead  us  to  believe,  that  Dr.  Jones  has  erred  in  the 
explanation  which  he  has  given  of  the  fact,  that 
an  ill  formed  ligature  prevents  obliteration  of  the 
artery.  We  can  easily,  independent  of  Dr.  Jones? 
idea,  comprehend  how  an  unequal  ligature  will 
frustrate  the  end  for  which  it  is  employed.  The 
adhesive  inflammation  is  a delicate  process,  one 
which  will  be  equally  injured  by  too  high  or  too 
low  a stimulus.  If  an  uneven  thread  be  used, 
the  inflammation  excited  runs,  perhaps,  too  high, 
or  on  the  other  hand,  if  the  vessel  be  torpid, 
which  frequently  happens  in  aneurismal  patients, 
a sufficient  action  is  not  brought  on.  But  all  this 
is  independent  of  what  Dr.  Jones  supposes,  being 
totally  uninfluenced  by  the  internal  coats  being 
either  cut,  or  the  reverse. 

Indeed,  the  tying  of  an  artery  in  aneurism,  is 
in  no  respect  different  from  tying  it  after  amputa- 
tion. In  the  latter  case,  the  ligature  is  applied 
by  wise  men  and  fools,  and  in  every  possible  way 
that  can  be  conceived;  yet  it  does  not  fail  to  pro- 
duce adhesion,  perhaps  once  in  a thousand  instan- 
ces. In  aneurism,  secondary  haemorrhage  is  fre- 
quent, but  it  is  surely  to  be  attributed,  in  most 
cases,  to  improper  treatment  of  the  vessel,  or  to  a 
diseased  state  of  its  coats.  The  same  ligatures 
which  succeed  after  amputation,  fail  in  aneurism, 


150  ON  THE  SURGICAL  ANATOMY 

which  unquestionably  implies  that  the  fault  lies 
not  in  the  thread,  but  either  with  the  operator  or 
the  vessel. 

Were  the  internal  coat  of  an  artery  possessed 
of  cellular  tissue,  the  process  of  adhesion  would 
not  be  so  ticklish.  When  we  failed  to  procure 
reunion  by  the  first  intention,  it  might  be  accom- 
plished by  granulation;  but  Bichat  has  shewn 
that  the  formation  of  granulations  is  a property 
not  possessed  by  the  internal  coats  of  arteries. 
When,  therefore,  reunion  by  the  first  intention 
is  lost,  all  is  lost.  A knotty  thread,  improperly 
applied,  irritates  the  artery  to  which  it  is  applied, 
beyond  the  degree  requisite  for  the  secretion  of 
organized  lymph;  acute  inflammation  is  excited, 
which  is  soon  followed  by  ulceration.  But  as 
the  inner  coats  of  arteries  possess  no  power  of 
forming  granulations,  subsequent  adhesion  can- 
not be  expected.  The  vessel  beyond  the  ligature 
gives  way  and  secondary  haemorrhage  takes  place. 

The  way  in  which  the  artery  itself  is  treated, 
at  the  time  the  ligature  is  applied,  is  another  fre- 
quent cause  of  secondary  bleeding.  By  Dr.  Jones 
it  has  been  ascertained,  that  the  coats  of  arteries 
depend  for  their  support  on  the  small  vessels, 
which  are  traced  creeping  among  the  meshes  of 
the  outer  layer  of  the  external  coat.  He  has 
also  satisfactorily  demonstrated,  that  these  are  de- 
rived from  the  branches  in  the  vicinity,  and  has 
proved  that  each  individual  part  of  the  artery  is 


OP  THE  HEAD  AND  NECK. 


151 


supplied  by  its  own  appropriate  vessels,  which 
do  not  freely  anastomose  with  those  above  or 
below.  Having  established  these  facts,  he  drew 
this  fair  practical  inference  from  his  data:  that 
an  insulated  part  of  the  artery  being  deprived 
of  its  vascular  connexions,  and  fairly  detached 
from  its  nutrient  twigs,  is  almost  certain  to  die,  and 
thence  to  separate,  in  a few  days,  from  the  still 
living,  but  inflamed  part  of  the  vessel.  To  pre- 
vent this,  which  had  formerly  been  the  bane  of  the 
operation,  he  advised,  that  uniformly  the  thread  be 
tied  as  nearly  as  possible  to  the  part  where  the  ves- 
sel is  still  adhering.  If  it  be  done  otherwise,  it  is 
evident  that  the  obliteration  of  the  vessel  must  be 
very  precarious,  it  can  only  be  accomplished  by 
the  insulated  part  of  the  artery  being  instantly 
almost  laid  in  contact  with  the  neighbouring  parts, 
to  which  it  will  adhere,  perhaps,  as  often  as  a 
tooth  transplanted  into  a cock’s  comb  will.  In 
this  way,  in  a small  proportion  of  cases,  oblitera- 
tion may  take  place,  but  much  oftener  it  will  fail 
to  be  accomplished. 

“When  we  consider  that  the  arteries  receive 
their  vessels  from  the  surrounding  cellular  mem- 
brane, it  must  be  evident,  that  if  we  deprive  them 
of  those  vessels,  they  cannot  undergo  those  changes 
which  depend  on  vascularity,  viz.  inflammation 
and  adhesion;  and,  consequently,  the  ligature 
cannot  produce  those  eflects  on  which  the  success 
of  the  operation  depends,  but  the  portion  of 


152  ON  THE  SURGICAL  ANATOMY 

artery  dying,  bursting  or  sloughing,  haemorrhage 
takes  place.  If  the  ligature  be  applied  on  the 
centre  of  the  detached  portion  of  the  artery,  when 
the  artery  gives  way,  the  haemorrhage  will  pro- 
ceed both  from  the  upper  and  the  lower  portions; 
but  if  it  be  applied  on  the  vessel  at  its  connexion 
with  the  surrounding  cellular  membrane,  either 
above  or  below,  the  haemorrhage  will  then  pro- 
ceed from  only  one  part  of  the  artery,  which  will 
be  that  which  has  the  detached  portion  of  the 
artery  for  its  extremity.  As  the  haemorrhage 
will  supervene,  as  soon  as  the  smallest  part  of  the 
artery  has  given  way,  of  course  it  will  frequently 
return,  and,  perhaps,  even  prove  fatal,  before  the 
artery  is  divided  into  two  distinct  portions;  and 
hence  we  almost  always  find  the  secondary  hae- 
morrhage described  as  issuing  from  the  artery 
immediately  under  the  ligature.”* 

Secondary  haemorrhage  is  often  dependent  on 
the  formation  of  sinuses  along  the  course  of  the 
artery.  These,  when  extensive,  insulate  the  ves- 
sel as  effectually  as  the  fingers  of  the  surgeon; 
they  deprive  its  coats  of  their  nourishment,  they 
consequently  give  way,  and  profuse  bleeding  takes 
place.  This  cause  of  secondary  haemorrhage  is 
especially  apt  to  occur,  if  there  be  diseased  glands 
round  the  vessel.  When  these  suppurate,  the 
artery  is  detached,  or  the  ulceration  penetrates 
into  its  cavity.  The  case  of  inguinal  aneurism. 


Searpa.  p.  269. 


OF  THE  HEAD  AND  NECK-  153 

first  operated  on  by  Mr.  Abernethy,  affords  a 
good  illustration  of  this  species  of  secondary  hae- 
morrhage. 

Taking  up  too  much  surrounding  substance 
along  with  the  artery,  is  another  cause  giving 
rise  to  secondary  haemorrhage.  At  the  moment 
of  tying  the  ligature,  the  proper  degree  of  irrita- 
tion is  not  applied  to  the  vessel,  and  by  the 
shrinking  of  the  parts  the  pressure  on  the  artery 
is  not  kept  up  for  a sufficient  length  of  time;  the 
artery  begins  again  to  allow  blood  to  pass  through 
its  canal,  and  the  formation  of  organized  lymph 
is  prevented.  I suspect  that  this  cause  of  secon- 
dary bleeding  will  chiefly  have  effect  where  the 
artery  is  torpid. 

There  is  also  another  way,  in  which  including 
some  of  the  parts  in  the  vicinity,  may  tend  to 
prevent  obliteration  of  the  artery.  It  is  a well 
known  fact,  that  a nerve,  if  taken  in,  prevents  for 
a great  length  of  time  the  separation  of  the 
thread.  If,  therefore,  we  have  included  one, 
the  ligature  remains  long  a source  of  irritation, 
at  the  extremity  of  the  vessel.  The  surgeon  also 
is  often  tempted  to  pull  at  it,  endeavouring  to 
bring  it  away.  It  cannot  be  a matter  of  wonder 
that  these  causes,  conjoined,  should  excite  acute 
inflammation  in  the  parts  acted  on,  followed  by 
ulceration,  nor  that  this  should  eventually,  in 
some  cases,  penetrate  into  the  vessel  above  where 
it  is  obliterated. 

20 


154 


ON  THE  SURGICAL  ANATOMY 


Where  the  haemorrhage  arises  from  the  shrink- 
ing of  the  parts  included  in  the  ligature,  it  occurs 
shortly  after  the  operation,  but  where  it  is  depen- 
dent on  a nerve  having  been  included,  it  does  not 
take  place  for  days  or  weeks.  The  production  of 
secondary  haemorrhage  is,  I believe,  the  chief  bad 
effect  which  will  generally  result  from  including  a 
nerve;  although  some  are  to  be  found  who  assert, 
that  this  almost  uniformly  gives  rise  to  convul- 
sions, which  is  by  no  means  the  ease.  At  the 
same  time,  that  I would  not,  on  that  account, 
dread,  as  some  do,  the  taking  up  a nerve  along 
with  the  artery,  still,  I cannot  look  on  including 
a nerve  to  be  immaterial,  notwithstanding  the 
authority  of  Scarpa,  who,  in  speaking  of  applying 
a ligature,  to  the  femoral  artery,  observes,  that 
the  nervous  twigs  may  be  separated,  in  laying 
bare  and  detaching  the  vessel  from  the  cellular 
membrane;  “or  if  they  even  remain  along  with 
the  artery,  included  in  the  ligature,  the  loss  of 
them  has  no  material  influence  in  relation  to  the 
sensation  of  the  lower  extremity."* 

There  are  other  causes,  besides  those  enume- 
rated, which  give  rise  to  secondary  haemorrhage. 
The  ligature,  in  some  cases,  slips  from  the  artery, 
and  the  bleeding  begins  before  the  patient  is  re- 
moved from  the  table.  Dr.  Jones  observes,  that 
surgeons  have  always  excused  themselves  when 
this  happened,  by  saying,  that  it  was  dependent 

* Scarpa,  page  269. 


OF  THE  HEAD  AND  NECK. 


155 


on  the  violent  impulse  of  the  blood,  against  the 
tied  end  of  the  artery.  His  experiments  prove 
this  to  be  a mistaken  notion.  We  have  certain 
information  from  them,  that  very  soon  that  por- 
tion of  the  vessel  between  the  ligature  and  the 
first  lateral  branch  ceases  to  pulsate  at  all;  nay, 
even  where  the  distance  between  them  is  consi- 
derable, the  blood,  from  stagnation,  soon  coagu- 
lates. The  impulse  of  the  blood,  cannot,  then,  in 
general,  be  the  cause  why  the  ligature  slips  from 
the  vessel.  Dr.  Jones  more  rationally  explains 
this,  by  supposing  it  to  have  arisen  “either  from 
the  clumsiness  of  the  ligature,  which  prevented  its 
tying  compactly  and  securely  round  the  artery; 
or  from  its  not  having  been  applied  tight  enough, 
lest  it  should  cut  through  the  coats  of  the  artery 
too  soon;  or  finally,  from  its  having  that  very  in- 
secure hold  of  the  artery,  which  the  deviation 
from  the  circular  direction  must  necessarily  occa- 
sion.” It  is  obvious,  that  these  causes  may  be 
variously  combined  in  the  same  case;  and  if  one 
be  adequate  to  occasion  the  slipping  of  the  liga- 
ture, how  much  more  likely  is  that  event  to  hap- 
pen, when  they  are  so  combined? 

I have  known  one  instance,  where  the  surgeon 
tied  the  sheath  formed  in  the  substance  of  the 
triceps  muscle,  mistaking  it  for  the  femoral  artery 
which  had  retracted  itself.  In  this  case,  the  liga- 
ture, maintained  its  place  so  long  as  the  patient 
lay  in  a fainting  state  on  the  table,  but  so  soon  as 


156 


ON  THE  SURGICAL  ANATOMY 


he  was  put  to  bed,  it  was  forced  off,  and  the  bed 
was  deluged  with  blood.  Indeed,  the  life  of 
the  person  was  only  saved  by  the  use  of  the 
tourniquet;  by  undoing  the  dressings,  exposing 
the  face  of  the  stump,  clearing  away  the  elct  ed 
blood,  and  slitting  up  the  sheath  of  the  artery 
so  far,  that  a tenaculum  could  be  fairly  thrust 
through  the  coats  of  the  exposed  vessel. 

These  causes,  by  attention,  may  be  obviated; 
where,  therefore,  they  operate,  the  surgeon  is 
blameable  for  the  way  in  which  he  has  applied 
the  ligature.  It  appears  to  me,  that  the  only 
way  in  which  the  slipping  of  the  ligature  can  take 
place,  without  being  imputable  to  the  surgeon,  is, 
when  the  internal  coat,  “ tissu  arteriel ,”  and  inner 
layer  of  the  external  coat  are  greatly  diseased. 
In  such  a case,  the  surgeon,  while  detaching  the 
artery  from  the  neighbouring  parts,  may  strip  off 
the  external  loose  and  shaggy  covering;  or  even 
should  this  be  left,  on  tying  the  thread,  all  the 
diseased  coats  will  be  divided,  the  blood  will  in- 
stantly distend  the  cells,  and  escape  from  the 
meshes  of  the  spongy  outer  covering;  or  where 
this  has  been  stripped  off,  the  stream  will  flow 
from  the  gaping  orifice  of  the  vessel  itself.  We 
have  reason  to  be  satisfied  that  these  are  the 
chief  causes  which  occasion  slipping  of  the  liga- 
ture; and  if  this  be  admitted,  there  can  surely  be 
no  propriety  in  attempting  to  prevent  its  detach- 
ment by  stitching  it  to  the  vessel,  as  has  been 


OF  THE  HEAD  AND  NECK. 


157 


lately  proposed.  Such  a plan  cannot,  in  any 
case,  add  to  the  security;  for  it  cannot,  where  the 
ligature  would  be  detached,  prevent  this  from, 
happening;  and  when  this  would  not  happen,  it 
must  be  a superfluous  precaution,  one  which,  as 
it  can  never  be  required,  ought  never  to  be  em- 
ployed. 

Even  where  the  artery  is  not  so  much  diseased 
as  I have  been  supposing,  still  if  it  be  not  per- 
fectly healthy,  although  it  may,  for  a few  days 
retain  the  ligature,  adhesion  will  not  take  place. 
Hence,  in  aged  people,  in  whom  this  alteration 
from  the  natural  state  is  very  frequent,  oblitera- 
tion is  more  rarely  obtained  than  in  young  pa- 
tients. I believe,  that  this  deviation  from  the 
healthy  structure,  is  not  only  a direct  cause,  pre- 
venting adhesion  where  an  artery  is  tied,  but  also 
that  it  indirectly  prevents  the  obliteration.  It  is 
now  certainlv  ascertained,  that  the  circulation 
along  that  part  of  the  vessel  which  is  between  the 
ligature  and  the  first  lateral  branch,  ought,  in  the 
course  of  a very  short  time  after  the  application 
of  the  ligature,  to  be  completely  cut  off*.  This  is 
produced  by  the  contraction  of  the  artery  by  its 
muscular  power,  till  at  last,  where  the  distance  is 
short  between  the  thread  and  the  first  branch,  its 
sides  are  brought  into  accurate  apposition.  This 
contraction  of  the  vessel,  and  the  excitation  of 
such  an  increase  of  action  on  its  inner  surface,  as 
shall  procure  a due  secretion  of  organized  lymph, 


158 


ON  THE  SURGICAL  ANATOMY 


are  indispensable  to  the  perfect  obliteration  of  its 
canal;  but  as  neither  can  be  accomplished  where 
the  internal  coats  are  in  a morbid  condition,  so 
adhesion,  and  consequent  obliteration,  cannot, 
under  such  circumstances,  be  effected.  Sooner 
or  later,  secondary  haemorrhage  will  take  place. 
Secondary  haemorrhage,  from  this  diseased  state 
of  the  coats  of  an  artery,  Mr.  C.  Bell  says,  will 
generally  take  place  “during  the  period  from  the 
tenth  to  the  fifteenth  day  after  the  operation.”* 

Dr.  Jones  mentions  among  the  causes  of  se- 
condary haemorrhage,  premature  exertion  of  the 
patient,  producing  rupture  of  the  newly  formed  ci- 
catrix; but  this,  I imagine,  can  only  happen  where 
the  ligature  has  been  applied  very  near  to  a late- 
ral branch.  In  that  case,  I can  suppose,  that  from 
the  small  portion  of  the  artery  which  has  been  ob- 
literated, especially  if  its  extremity  be  not  sup- 
ported by  granulations  from  the  surrounding  parts, 
an  increased  impetus  of  circulation  may  burst 
open  the  slender  adhesion.  It  must,  however,  be 
confessed,  that  the  occurrence  is  just  within  the 
verge  of  possibility. 

The  effects  resulting  from  the  application  of  a 
ligature  to  an  artery,  and  the  causes  giving  rise  to 
secondary  hemorrhage,  having  been  now  attended 
to,  we  are  in  the  next  place  to  trace  the  history  of 
the  various  modes  of  operating  for  aneurism,  at 

* Beil’s  Operative  Surgery,  vol.  i.  page  82. 


OF  THE  HEAD  AND  NECK.  159 

least,  in  so  far  as  this  is  necessary  to  illustrate  the 
causes  tending  to  occasion  failure  of  each  of  these, 
and  to  enable  us  to  determine  which  is  the  prefer- 
able plan  of  operating,  or  the  one  least  subject  to 
be  followed  by  secondary  haemorrhage. 

I would  conceive  it  nearly  a waste  of  time  to 
describe  the  modes  of  operating  adopted  by  our 
ancestors,  at  least  minutely.  Suffice  it  to  say, 
that  they  all  had  a notion  that  it  was  necessary  to 
cut  on  the  sac,  and  tie  the  artery  at  its  entrance 
into,  and  passage  from  the  cyst;  nay,  some  before 
they  did  this,  tied  the  artery  with  a double  liga- 
ture, a considerable  way  above  the  tumour;  some 
fairly  dissected  out  the  sac,  while  others  were  sa- 
tisfied with  opening  it,  removing  its  contents,  and 
allowing  it  to  slough  off,  or  be  removed  in  the  way 
most  agreeable  to  nature.  Such  operations,  how- 
ever, it  is  demonstrable  could  seldom  succeed. 
The  parts  operated  on,  were,  from  their  morbid 
condition,  prone  to  disease;  obliteration  of  the  ca- 
nal of  the  artery  seldom  took  place;  secondary 
haemorrhage  generally  followed  the  operation,  or 
large  and  extensive  sloughs  were  cast  off,  profuse 
suppurations  succeeded,  the  sore  was  long  of  gra- 
nulating, and  even  where  after  great  risk  and  pro- 
tracted suffering,  a cure  was  obtained,  recovery 
was  imperfect,  for  the  limb  was  much  injured. 
No  wonder  that  surgeons  should  have  generally 
declined  this  operation;  for  as  performed  till  the 
time  of  Anel  and  Hunter,  its  advantages  were 


160 


ON  THE  SURGICAL  ANATOMY 


fully  counterbalanced  by  its  inconveniences.  The 
improvements  of  the  day,  or  as  they  ought  to  be 
called,  the  alterations,  added  to  the  danger  of  the 
operation.  They  were  the  offspring  of  erroneous 
notions,  and  imperfect  anatomy. 

If  ever  we  are  to  attain  to  uniform,  or  nearly 
uniform  success  in  our  operations,  it  must  be  by 
having  investigated  and  obviated  the  causes  of 
failure.  Many  surgeons  have  misapplied  that 
time  in  the  invention  of  new  instruments,  which 
ought  to  have  been  devoted  to  the  study  of  the 
causes  producing  secondary  haemorrhage.  This 
cannot  be  more  completely  illustrated,  than  by  re- 
viewing  the  plans  devised  by  our  forefathers,  to 
prevent  the  occurrence  of  that  accident.  They 
had  recourse  to  mechanical  contrivances,  to  accom- 
plish an  object  which  could  only  be  attained  by  a 
more  correct  knowledge  of  the  structure  of  the 
parts  operated  upon.  They  frequently  witnessed 
secondary  haemorrhage,  and  no  wonder,  consider- 
ing the  way  in  which  they  treated  the  artery,  and 
the  high  irritation  they  excited  in  its  vicinity. 
Their  ignorance,  however,  led  them  to  employ 
means  which  would  have  a diametrically  opposite 
effect  from  the  one  intended.  They  introduced 
threads  of  reserve,  a practice,  which,  I believe, 
originated  with  Paulus;  but  these,  so  far  from  an- 
swering the  purpose  for  which  they  were  used: 
were  really  a source  of  imminent  danger.  Their 
employment  could  not  be  justified  by  a single 


OP  THE  HEAD  AND  NECK. 


161 


reasonable  argument.  Mechanical  speculation  in- 
troduced them,  and  the  eager  anxiety  of  the  sur- 
geon to  assist  nature,  kept  up  the  practice. 

It  was  hardly  reasonable,  however,  to  suppose 
that  the  clumsy  means  which  were  often  employed, 
would  really  aid  the  actions  of  the  living  system. 
The  promoters  of  such  practices  would  have  done 
wisely,  had  they  recollected,  in  the  performance  of 
their  operations,  and  in  their  endeavours  to  assist 
nature,  that  whatever  is  not  alive  must  retard,  in 
place  of  expediting  the  cure.  Hence  it  comes, 
that  the  reserve  ligatures,  the  quills,  the  leather, 
and  the  silver  pads,  and  numerous  other  machines, 
contrived  by  the  French  surgeons,  so  often  failed. 
In  fact,  they  increased  the  evil  they  were  in- 
tended to  remove.  This  may  be  proved  by  re- 
viewing the  records  of  surgery,  which  are  filled 
with  cases  of  secondary  bleeding,  and  new  and 
mechanical  contrivances  introduced  to  counteract 
the  evil.  This,  however,  was  not  the  way  to  les- 
sen the  danger,  nor  could  the  invention  of  such 
instruments  be  considered  as  improvements  in  our 
art. 

The  first  real  improvement  of  this  operation 
was  brought  forward  about  the  commencement  of 
the  eighteenth  century  by  Anel.  In  his  opera- 
tion, two  ligatures  were  tied  on  the  artery,  con- 
tiguous to  each  other,  and  the  tumour  was  left  to 
decrease  by  operations  carried  on  within  itself. 
As  the  agency  of  the  absorbent  system  was  not 
21 


162 


ON  THE  SURGICAL  ANATOMY 


understood  in  the  early  part  of  that  century,  we 
cannot  wonder  that  Anel  should  have  explained 
the  mode  in  which  the  tumour  was  removed  by 
nature,  on  false  principles;  nor  is  it  matter  of  sur- 
prise, that  he  should  have  ascribed  to  another  and 
imaginary  power,  what  was  really  due  to  the  lym- 
phatics. 

Anel  does  not  seem  to  have  proceeded  on  any 
fixed  principle  in  this  operation,  which  appears 
to  have  been  only  a modification  of  the  plan  pur- 
sued by  Etius,  who  first  tied  two  ligatures  round 
the  vessel,  a considerable  way  above  the  tumour, 
and  then  divided  the  artery  in  the  space  be- 
tween them;  had  he  rested  here,  his  operation 
would  have  been  as  perfect  as  the  present  one,  of 
which  it  is,  indeed,  the  rough  original.  When, 
however,  he  had  performed  this,  which  was  all 
that  was  really  required,  he  proceeded  to  ope- 
rate on  the  tumour,  which  no  one,  in  his  time, 
could  believe  would  be  removed  by  the  efforts  of 
the  system  itself;  their  knowledge  of  the  animal 
economy  did  not  extend  thus  far,  nor  wTere  they 
certain  how  the  limb  was  to  be  supported  after  the 
main  artery  was  tied.  The  notions  of  medical 
men  w7ere,  on  this  subject,  highly  absurd,  till  the 
time  of  Mr.  Hunter. 

One  can  hardly  conceive,  nowT  that  he  knows 
the  certainty  introduced  into  this  operation,  the 
feelings  which  agitated  our  ancestors,  when  about 
to  enter  on  its  performance.  They  wrere  ignorant 


OF  THE  HEAD  AND  NECK. 


163 


•of  the  great  and  striking  effects  produced  by 
vascular  inosculation;  and  they  would  have  start- 
ed, had  they  been  told,  that  their  sole  depen- 
dence ought  to  be  placed  on  the  delicate  rami- 
fications of  arteries, — for  the  support  of  the  limb 
beneath,  after  the  operations  for  aneurism.  We 
now  place  no  reliance  on  the  supposititious  and 
unusual  branches  of  the  older  surgeons;  we 
have  no  faith  in  a high  division  of  the  main 
artery  being  at  all  necessary  to  the  safety  of 
the  limb.  We  have  this  superiority  over  our 
ancestors,  that  we  know  by  experience' that  the 
power  of  the  anastomosing  arteries  is  great;  we 
place  our  trust  in  them;  we  do  not  now  pro- 
ceed with  fear  and  trembling  to  the  operation 
for  aneurism,  and  wonder  at  our  success — we  en- 
ter on  it  boldly,  and  convinced  of  the  resources  of 
the  system,  we,  without  hesitating,  tie  the  large 
artery  of  any  limb,  and  yet  have  little  dread  of 
the  member  dying  from  want  of  nourishment. 
This,  although  much  dreaded  by  those  who  have 
gone  before  us,  is  not  the  source  of  danger  in  this 
operation,  which  has  already  been  shewn  to  arise 
principally  from  secondary  bleeding,  which  the 
ancients  ineffectually  attempted  to  prevent  by 
their  mechanical  inventions. 

We  are  now  to  attend  to  this  operation  as 
modified  by  Mr.  John  Hunter,  whose  chief  im- 
provements in  surgery,  and  in  the  operation  for 
aneurism,  in  particular,  arose  from  his  extensive 


164 


ON  THE  SURGICAL  ANATOMY 


anatomical  knowledge,  and  from  his  unremitting 
attention  to  the  animal  economy.  He  was  indeed, 
the  introducer  of  several  new  modes  of  operating; 
hut  he  was  the  inventor  of  few  instruments.  I 
have  already  mentioned  the  state  of  this  opera- 
tion at  the  time  Mr.  Hunter  began  to  practise 
surgery;  and  with  the  exception  of  the  single  ope- 
ration performed  towards  the  beginning  of  the 
eighteenth  century  by  Anel,  it  has  been  seen  in 
a rude  and  defective  state.  Those  who  view 
with  an  impartial  eye,  the  records  of  surgery 
previous  to  the  time  of  Mr.  Hunter,  must  be  con- 
vinced that  much  of  our  present  success  is  justly  to 
be  attributed  to  the  labours  of  that  distinguished, 
pathologist.  Some  may  here  say,  that  Anel  laid 
the  foundation  of  our  practice;  but  this,  on  reflec- 
tion, can  hardly  he  admitted,  since,  although  Anel 
did  really  perform  an  operation  similar  to  the  one 
introduced  by  Mr.  Hunter,  yet  his  practice  was 
soon  forgotten,  chiefly,  because  not  fully  and 
scientifically  explained  even  by  himself.  Mr. 
Hunter,  on  the  other  hand,  showed  that  one  prin- 
cipal cause  of  failure,  was  secondary  haemorrhage, 
which,  in  his  opinion,  was  occasioned  by  tying 
the  artery  too  near  the  seat  of  disease:  A morbid 
part  of  the  vessel  was  acted  on,  obliteration  of 
its  canal,  for  reasons  already  explained,  seldom 
took  place.  He  being  convinced,  that  want  of 
success  depended  on  this  cause,  proposed  taking 
lip  the  vessel  at  some  distance  from  the  tumour,  at  a 


OF  THE  HEAD  AND  NECK. 


165 


part  where  we  might  naturally  expect  it  to  be  in 
a healthy  state.  He  acted  on  this  idea,  but 
although  he  was  rather  more  fortunate  than  those 
who  had  gone  before  him,  still  he  could  not  boast 
of  complete  success;  secondary  haemorrhage  was  a 
frequent  occurrence;  still,  therefore,  the  operation 
was  thus  far  defective. 

Mr.  Hunter  was  most  assuredly  the  first  who 
proceeded  on  rational  principles  to  improve  the 
operation;  but  it  may  be  worth  while  to  explain 
why  he  failed  to  bring  it  to  its  present  perfection. 
In  the  first  operation  which  he  performed,  which 
was  in  the  year  1785,  he  detached  a considerable 
part  of  the  vessel  from  its  nutrient  twigs,  and  then 
he  tied  four  ligatures  round  the  detached  part,  but 
the  one  farthest  from  the  heart  being  only  pulled 
tight,  was  really  the  ligature  which  cut  off  the  cir- 
culation; the  other  three  were  reserve  ligatures. 
This  statement  is  of  itself  a sufficient  explanation 
why  haemorrhage  took  place;  and  if  he  afterward 
abandoned  the  reserve  ligatures,  still  he  gained  but 
little,  for  he  continued  to  insulate  too  much  of  the 
artery — he  applied  the  thread  on  a part  deprived 
of  its  circulation. 

Mr.  Hunter’s  plan,  therefore,  only  obviated  one 
cause  of  failure,  that  dependent  on  tying  a dis- 
eased part  of  the  artery;  it  left  the  other  causes 
as  liable  to  operate  as  formerly.  But  Mr.  Hun- 
ter did  a great  service,  by  proving  that  there  is 
no  propriety  in  touching  the  tumour.  He  shewed, 


166  ON  THE  SURGICAL  ANATOMY 


that  of  herself,  the  system  is  competent  to  procure 
its  removal,  after  the  circulation  through  it  was  cut 
off;  and  he  clearly  demonstrated  that  this  office  was 
performed  by  the  lymphatics.  This,  of  itself,  was 
a material  point  gained.  Mr.  Hunter  can  readily 
be  excused  for  not  having  accomplished  more, 
when  it  is  remarked,  that  till  after  his  time,  Dr. 
Jones’  experiments  were  not  performed.  While, 
therefore,  this  furnishes  an  apology  for  Mr.  Hun- 
ter, it  leads  me  to  mention  that  Dr.  Jones  and  Dr. 
Thomson,  by  their  ingenious  experiments  on  the 
arteries,  and  fair  deductions  from  these,  have 
brought  the  operation,  nearly,  we  presume,  to  its 
ultimate  perfection. 

Professor  Scarpa  has  made  some  alterations  on 
the  Hunterian  mode  of  operating,  which  must  be 
next  examined.  As  his  own  account  of  these  is 
sufficiently  concise,  I shall  make  no  apology  for 
transcribing  his  own  words.  “Of  all  the  steps  of 
this  operation,  the  following  points  deserye  par- 
ticular attention.”  Some  preliminary  observa- 
tions, as  relating  to  popliteal  aneurism  in  particu- 
lar, I omit,  “2dly,  The  manner  of  insulating  the 
artery  from  the  cellular  substance,  with  the  point 
of  the  finger,  rather  than  with  a cutting  instru- 
ment, in  order  to  prevent  in  this  way,  the  division 
of  any  collateral  branch;  and  the  insulating  the 
artery  only  in  that  place  which  is  required  for  the 
application  of  two  ligatures  near  to  each  other, 
and  of  a cylinder  of  linen  corresponding  exactly 


OF  THE  HEAD  AND  NECK. 


167 


to  the  breadth  of  the  point  of  the  finger,  or  a little 
more.  3dly,  The  ligature,  by  means  of  two  waxed 
tapes  of  convenient  breadth,  placed  behind  and 
round  the  artery,  near  to  each  other,  with  the  in- 
terposition of  a roll  of  linen  of  a cylindrical  form, 
between  the  artery  and  the  knot.  4thly,  The  ex- 
press omission  of  the  ligature  of  reserve,  othly, 
The  giving  the  preference  to  the  single,  rather 
than  to  the  double,  or  surgeon’s  knot.  6thly,  The 
unremitting  attention,  during  the  subsequent  cure, 
that  the  lips  of  the  wound  do  not  approach  too 
near;  and  still  more,  that  they  do  not  adhere  to- 
gether, before  the  ligatures  and  the  roll  of  linen 
are  expelled  from  the  bottom  of  the  wound,  and 
till  the  bottom  of  the  wound  has  risen  nearly  to  a 
level  with  the  integuments.  7thly,  The  timely  in- 
cision or  counter  opening  in  the  case,  although  it 
is  not  frequent,  of  an  abscess  forming  in  the  vi- 
cinity, or  along  the  course  of  the  artery,  occasioned 
by  the  portion  of  cellular  substance  surrounding 
the  artery  passing  into  mortification.” 

This  is  a correct  outline  of  the  practice  of  the 
Italian  professor;  yet  high  as  his  authority  is,  to 
most  who  are  acquainted  with  Dr.  Jones’  expe- 
riments, many  parts  of  his  practice  must  appear 
objectionable.  What  difference  is  there  between 
a roll  of  linen  laid  along  the  artery,  and  a ligature 
of  reserve  placed  loosely  around  its  canal?  The  one 
is  not  more  injurious  than  the  other,  for  the  roll 
of  linen  is  prejudicial  in  proportion  to  the  degree 


168 


ON  THE  SURGICAL  ANATOMY 


of  over-action  it  excites.  The  only  way  in  which 
I can  comprehend  how  Scarpa  has  succeeded  so 
often,  is,  by  supposing  that  the  roll  of  linen  was 
chiefly  applied  to  the  insulated  and  dead  part  of 
the  artery,  between  the  ligatures.  Had  it  been 
otherwise,  it  must  have  been  more  injurious  than 
it  seems  to  have  been. 

It  has  already  been  mentioned,  that  adhesion  is 
a more  delicate  process  in  arteries,  than  in  other 
parts.  Dr.  Jones’  experiments  shew,  that  trivial 
causes  derange  and  prevent  its  completion;  and 
that  no  agent  has  a more  powerful  tendency  to  do 
this,  than  the  excitation  of  ulceration  in  the  vici- 
nity of  the  newly  obliterated  artery.  Yet  so  far 
from  wishing  to  avoid  this,  we  are  told  by  Scarpa 
that  our  success  is  to  be  regulated  by  procuring 
it.  Where  the  testimony  of  authors  is  so  contra- 
dictory, who  shall  decide? 

Dr  Jones  appeals  to  carefully  performed  ex- 
periments, and  Scarpa  ranges  in  order  his  long 
train  of  arguments,  and  his  comparative  estimate 
of  success.  It  is,  however,  to  be  remembered, 
that  Scarpa’s  facts,  observations,  and  conclusions, 
are  all  drawn  from  cases  prior  to  the  publication  of 
Dr.  Jones’  work,  which  he  does  not  appear  to 
have  seen.  His  success  can,  therefore,  only  be 
compared  with  that  of  the  operations  performed 
on  the  original  Hunterian  mode,  which  we  have 
already  seen  was  defective.  When  consequently, 
we  grant  that  the  mode  of  operating  introduced 


OF  THE  HEAD  AND  NECK. 


169 


by  Scarpa,  in  so  far  as  it  wants  the  reserve  liga- 
ture, and  in  so  far  as  it  preserves  the  wound 
open,  till  all  extraneous  substances  are  removed,  is 
better  than  that  of  Hunter,  still  it  is  not  to  he  put 
in  comparison  with  the  mode  at  present  in  use  in 
this  country. 

Till  the  publication  of  Dr.  Jones’  work,  sur- 
geons, generally,  had  no  very  distinct  notion  of 
the  manner  in  which  the  coats  of  arteries  are 
supplied  with  nourishment.  Few  troubled  them- 
selves with  such  inquiries;  and  most,  I believe, 
supposed  that  the  vasa  vasorum  derived  their 
blood  from  the  main  trunk  of  the  artery  itself. 
Dr.  Jones  corrected  our  ideas  on  this  subject; 
for  he  clearly  demonstrated,  that  the  blood  which 
circulates  in  the  vasa  vasorum  is  obtained  from 
the  neighbouring  branches.  Hence,  if  these  be 
destroyed,  although  the  large  trunk  be  kept  full 
of  blood,  the  coats  of  the  vessel  must  die  from 
want  of  nourishment.  Had  Dr.  Jones  done  no- 
thing else  than  made  generally  known  the  mode 
by  which  the  vessels  are  nourished,  he  would 
have  performed  a most  valuable  service  to  surgery. 
It  was  too  often  the  practice,  before  his  observa- 
tions were  made  public,  to  detach  a consider- 
able part  of  the  artery,  and  to  apply  the  liga- 
ture round  some  part  of  the  insulated  portion  of 
the  vessel.  His  observations  have  shewn  the  im- 
propriety of  this  practice,  which  is  now  generally 
abandoned. 

22 


170 


ON  THE  SURGICAL  ANATOMY 


We  now  disturb  the  artery  as  little  as  possible* 
and  we  either  tie  one  ligature  of  proper  tight- 
ness round  it,  or  we  apply  two  ligatures,  one  as 
high  up,  and  the  other  as  low  down  as  the  vessel 
has  been  detached,  and  divide  the  artery  in  the 
space  between  them,  as  was  done  by  Etius,  and 
which  has  been,  with  great  propriety,  lately  re- 
vived by  Mr.  Abernethy.  Notwithstanding  the 
general  opinion,  that  the  latter  is  the  preferable 
mode,  Dr.  Jones  has  demonstrated,  that  when 
properly  executed,  the  single  ligature  is  as  safe, 
and  as  certain  as  the  double  one.  The  more  fre- 
quent failure  of  the  single,  than  of  the  double  lig- 
ature, is  occasioned  by  the  improper  way  in 
which  it  is  applied.  There  are,  in  fact  direct 
experiments  to  prove,  that  the  apparent  superi- 
ority of  the  one  over  the  other,  is  not  to  be  justly 
attributed  to  the  intrinsic  merit  of  the  one  being 
greater  than  that  of  the  other.  When  two  threads 
are  employed,  one  is  put  as  high,  and  the  other 
as  low  as  possible  on  the  artery,  which  is  thus, 
where  tied,  left  adhering  to  its  nutrient  twigs;  but 
when  one  ligature  only  is  used,  it  is  generally 
placed  somewhere  on  the  insulated  part  of  the 
vessel.  This,  as  has  been  already  explained,  is 
productive  of  secondary  haemorrhage. 

The  single  thread  produces  a more  copious 
effusion  of  lymph  round  the  artery,  on  which  one 
part  of  the  security  depends,  than  the  double  lig- 
ature, provided  it  be  passed  round  the  vessel 


OF  THE  HEAD  AND  NECK. 


171 


without  detaching  it  from  its  adhesion  to  the  parts 
in  the  vicinity,  to  a greater  extent  than  is  abso- 
lutely required  to  allow  it  to  pass.  Although 
this  be  really  true,  yet  as  it  is  much  more  diffi- 
cult to  perform  the  one  operation  properly,  than 
the  other;  I have  no  wish  to  see  the  single  liga- 
ture revived,  even  now  that  we  are  aware  of  the 
causes  occasioning  its  failure,  and  can  obviate 
them. 

Let  us,  as  recommended  by  Mr.  Abernethy, 
employ  two  threads,  small,  round,  and  even, 
and  let  these  be  passed  round  the  artery, 
which  is  to  be  as  little  disturbed,  as  is  compati- 
ble with  their  passage,  and  then  let  one  be  tied 
pretty  tightly  at  the  highest  point  of  the  vessel, 
and  the  other  at  the  lowest,  then  cut  the  artery 
through  between  them.  Perhaps  this  may  be  all 
that  is  generally  required  to  procure  oblitera- 
tion of  the  canal  of  the  vessel;  but  where  the 
tient  is  of  an  irritable  habit,  it  will  be  proper 
to  lessen  still  farther  the  irritation,  by  removing 
one  end  of  each  ligature;  and  if  accidentally 
any  more  of  the  artery  should  have  been  insula- 
ted, than  was  barely  sufficient  to  permit  of  the 
application  of  the  ligatures,  I would  also  remove 
that  portion  intercepted  between  the  threads. 
This,  in  the  hands  of  a dextrous  surgeon,  will 
never  be  required;  but  unfortunately,  all  who 
undertake  to  operate,  are  not  equally  qualified; 
some  detach  a great  part  of  the  vessel,  which  if 


172  ON  THE  SURGICAL  ANATOMY 


left  in  the  wound,  must  prove  as  much  a source  of 
irritation  as  the  reserve  ligatures  of  the  ancients, 
or  the  linen  roll  of  Scarpa.  The  operation  may 
succeed  in  either  way;  but  unless  there  be  some 
positive  advantage  to  result  from  such  procedure, 
it  had  better  be  avoided.  As  a greater  than  just 
degree  of  irritation  must  prove  injurious,  we  are, 
in  every  instance,  to  endeavour  to  procure  adhe- 
sion of  the  wound  by  the  first  intention.  This  will 
add  materially  to  the  security  of  the  operation. 
Where,  however,  from  the  irritation  of  the  liga- 
ture, any  purulent  matter  forms  about  the  artery, 
we  are  immediately  to  enlarge  the  opening,  to  pre- 
vent the  formation  of  sinuses  round  the  vessel, 
which  by  detaching  the  artery  from  its  connexions 
with  the  neighbouring  parts,  tends  to  produce  se- 
condary haemorrhage. 

So  soon  as  the  ligature  is  tied  round  the  artery, 
the  tumour  becomes  flaccid  and  ceases  to  pulsate, 
the  vital  actions  of  the  limb  are  languid,  it  feels 
cold  and  weak,  it  is  benumbed,  and  almost  in  a 
state  of  paralysis.  It  seldom,  however,  remains 
long  in  this  condition,  generally  in  a few  hours  it 
begins  to  revive,  and  in  some  time  longer,  its  heat 
is  even  increased  one  or  two  degrees  above  that  of 
the  opposite  limb,  which  is  the  surest  sign  of  the 
success  of  our  operation;  it  tells  us  forcibly,  that 
the  circulation  is  established  in  its  new  channel, 
jmd  assures  us,  that  we  have  nothing  now  to  dread 
from  the  limb  dying  for  want  of  nourishment.  At 


OF  THE  HEAD  AND  NECK.  173 

first  when  the  circulation  begins  to  be  restored, 
there  is  a sensation  of  creeping  in  the  parts  below 
where  the  ligature  is  tied,  or  a feeling  as  if  cold 
water  had  been  poured  over  the  limb.  This,  in  a 
longer  or  shorter  time,  is  succeeded  by  a strong 
vibratory  action  of  the  anastomosing  arteries, 
which  are  conducting  the  circulation,  but  the  heat 
of  the  member  does  not  become  steady  for  a week 
or  two. 

Soon  after  the  operation,  the  tumour  ceases  to 
be  painful,  its  remaining  contents  are  absorbed,  its 
thickened  and  diseased  coats  are  taken  away  by 
the  lymphatics,  very  gradually  however,  yet  be- 
fore the  end  of  the  seventh  week,  if  the  tumour 
lias  not  been  very  large,  it  is  materially  reduced 
in  size,  but  for  some  months  it  can  be  distinguished 
as  a small  hard  knob.  In  proportion  to  the  de- 
crease of  the  tumour  the  oedema  lessens,  and  the 
limb  improves  in  strength. 

Some  surgeons  recommend  after-the  operation, 
that  stimulating  embrocations,  heated  bricks,  or 
bladders  filled  with  hot  water,  be  applied  to  the 
member  during  the  time  that  it  is  cold,  and  lan- 
guid in  its  circulation.  This  is  a most  pernicious 
practice;  all  that  we  are  really  called  on  to  do,  is 
by  rolling  the  limb  in  flannel,  and  placing  wool  or 
cotton  round  it,  to  prevent  it  from  losing  its  heat. 
If  we  stimulate  the  member,  we  destroy  it.  Who 
would  ever  think,  of  desiring  a patient  who  has 
fatigued  himself  by  a long  walk,  to  recruit  himself 


174 


ON  THE  SURGICAL  ANATOMY 


by  taking  a longer  one.  Any  man  in  his  senses, 
would  consider  such  an  advice  as  highly  absurd. 
Why  then,  in  local  debility,  call  on  the  limb  to 
perform  actions  which  must  be  fatal  to  it?  Care 
must  not  only  be  taken,  not  to  over-excite  the 
limb,  but  we  must  even  be  watchful  to  keep  the 
action  of  the  system  moderate.  The  propriety, 
and  absolute  necessity  of  this,  will  be  best  enforc- 
ed on  the  mind,  by  pointing  out  the  consequences 
which  resulted  from  increased  action  of  the  sys- 
tem, in  a person  who  had  been  operated  on. 

The  patient  was  a middle  aged  man,  in  whom 
the  aneurism  could  evidently  be  traced  to  have 
arisen  from  a sudden  motion  of  the  knee  joint. 
The  tumour  was  not  larger  than  a turkey’s  egg, 
was  perfectly  circumscribed,  not  very  painful,  and 
was  unaccompanied  with  oedema  of  the  limb  be- 
neath. Under  these  favourable  circumstances,  the 
operation  was  performed,  and  the  person  for  some 
days,  did  extremely  well.  The  functions  of  the 
limb  were  restored,  and  the  wound  was  nearly 
healed.  Indeed,  he  continued  to  mend  progres- 
sively, till  the  temperature  of  the  member  was 
fairly  established,  and  till  the  enlarged  anasto- 
mosing arteries  could  be  felt  pulsating,  and  the 
tumour  had  decreased  to  the  size  of  a pigeon’s 

egg- 

About  this  time,  from  an  accidental  cause 
which  need  not  be  specified:*  an  extremely 

*Mr.  Burns  from  a feeling  of  delicacy  towards  the  person  who  com= 
quitted  the  blunder,  does  not  specify  the  cause  which  produced  the  “irre- 


OF  THE  HEAD  AND  NECK. 


175 


irregular  action  of  the  system  was  brought  on, 
attended  with  great  prostration  of  strength,  and 
accompanied  with  inconscious  discharge  of  his 
urine  and  faeces.  His  stools  were  passed  so  fre- 
quently, that  it  was  almost  impossible  to  keep  him 
clean  and  comfortable.  In  this  state,  he  was  seen 
by  another  surgeon  and  myself.  From  the  fre- 
quency and  feebleness  of  the  pulse,  the  urgent 
diarrhoea,  the  rapid  sinking,  and  the  facies  hippo- 
cratica,  we  judged  it  proper  to  prescribe  a cordial 
mixture,  and  he  was  likewise  directed  to  take  a 
grain  of  solid  opium,  every  four  or  five  hours. 

By  these,  the  purging  was  checked  in  about 
ten  hours,  but  the  pulse  continued  frequent,  and 
became  fuller;  the  tongue  remained  foul,  and  the 
head  was,  at  times,  confused  and  painful.  The 
limb  which  had  been  operated  on,  felt,  since  the 
induction  of  the  debility,  and  previous  to  the  use 
of  the  stimuli,  cold,  but  he  could  move  it  freely; 
so  soon,  however,  as  the  stimuli  roused  the  system, 
he  complained  of  its  being  insulferably  hot.  This 
increased  heat  of  the  limb,  continued  for  about  a 
day  and  a half,  when  the  toes  and  part  of  the 
foot  became  of  a leaden  colour.  In  a few  hours, 

gular  action  of  the  system,”  as  1 however,  consider  that  without  this  know- 
ledge the  case  is  imperfect,  1 think  it  proper  to  state  the  fact.  The  pa~ 
tient’s  bowels  having  become  torpid,  he  '■ias  ordered  a purge,  to  contain 
some  jalap  and  six  grains  of  calomel.  The  individual  whose  duty  it  was 
to  prepare  the  medicine,  used  in  a mistake  the  tartar  emetic  instead  of 
the  calomel,  which  necessarily  had  the  effect  of  violently  exciting  the 
whole  system. — Ed, 


1 76  ON  THE  SURGICAL  ANATOMY 

the  dark  colour  of  the  toes  had  increased,  they 
were  now  deprived  of  sensation,  and  a few  vesi- 
cations  appeared  on  the  side  of  the  foot.  He 
was  desired  to  apply  cloths  dipped  in  campho- 
rated alcohol  to  the  foot,  and  internally  he  took 
small  quanties  of  wine,  together  with  as  much 
bark  as  the  stomach  would  bear. 

On  the  following  day  he  felt  better,  his  toes 
had  regained,  in  a considerable  degree,  their 
feeling,  and  the  vesications  and  discoloration  on 
the  foot  had  not  extended.  He  continued  to 
mend  during  other  two  days,  when  suddenly,  and 
without  any  obvious  cause,  his  foot  became  worse, 
his  mind  became  clouded,  his  countenance  anxious, 
his  pulse  sunk,  and  he  lost  all  relish  for  his  food, 
and  was  drenched  in  cold  perspiration.  At  this 
period,  he  was  incapable  of  speaking,  his  breath- 
ing was  laborious,  and  accompanied  with  a rat- 
tling noise,  his  eyes  were  fixed  and  glazed,  his 
jaw  fallen,  his  limbs  were  cold,  and  a gangrenous 
slough  had  formed  on  the  outer  surface  of  the  foot. 

The  camphorated  spirit  was  continued  to  the 
foot,  and  as  he  rejected  the  wine,  a tea  spoonfull 
of  tincture  of  cinchona  was  given  occasionally. 
By  persisting  in  the  use  of  this  medicine,  and  by 
adding  to  it  light,  digestible,  and  nourishing  diet, 
mixed  with  small  quantities  of  wine,  there  was  in 
the  short  space  of  two  days,  a material  improve- 
ment in  his  situation.  It  is  mentioned  in  the 
notes  I took  of  the  case,  “the  pulse  has  risen  in 


OP  THE  HEAD  AND  NECK; 


177 


strength,  the  eye  has  brightened,  the  counte- 
nance is  now  composed,  and  the  mind  is  serene, 
he  eats  with  considerable  relish,  and  has  recovered 
completely  his  speech.  The  foot  has  even  put  on 
a better  appearance,  the  slough  which  continues 
superficial,  has  not  spread,  the  rest  of  the  foot 
and  toes  are  less  livid,  and  begin  to  recover  their 
warmth  and  sensation;  he  has  no  pain  in  the  limb, 
and  in  every  respect  feels  easier.” 

By  perseverance  in  the  same  plan,  the  slough 
separated,  leaving  along  the  edge  of  the  foot  a sore 
by  no  means  as  large  as  might  have  been  expect- 
ed, from  the  alarming  appearance  which  the  foot 
at  one  time  presented.  By  dressing  the  sore  for 
a few  days  with  warm  dressings,  granulations 
began  to  form,  but  they  were  never  healthy, 
nor  did  they  ever  make  much  progress.  The 
general  system  had  received  an  irreparable  shock, 
from  which  it  could  never  recover.  After  one 
or  two  weeks  of  protracted  suffering,  he  died; 
yet  before  this  event  took  place,  both  ligatures 
had  come  away,  one  on  the  fourteenth,  and  the 
other  on  the  fifteenth  day,  and  the  wound  had 
healed. 

This  is  a curious  and  very  interesting  case. 
The  circulation  for  several  days  seemed  to  be  fully 
supported  by  the  anastomosing  vessels.  When  he 
was  seized  with  general  irregular  action,  from  this 
cause,  and  the  diarrhoea,  he  was  reduced  to  the 
last  stage  of  debility,  the  limb  which  had  been 
23 


178 


ON  THE  SURGICAL  ANATOMY 


operated  on,  being  still  in  a ticklish  state,  suffered 
more  than  the  rest  of  the  body.  It  felt  very  cold, 
hut  retained  its  colour  and  motion.  It  did  not  ap- 
pear to  suffer  materially  from  the  deficiency  of 
blood;  for,  although  more  weakened  than  the  other 
parts,  still  there  appeared  no  tendency  to  gan- 
grene. But  when  by  the  stimuli,  which  were  pre- 
scribed with  a view  to  support  the  system,  the  ac- 
tion of  the  whole  body,  was  increased,  that  of  the 
limb  was  also  augmented;  hut  from  the  previous 
reduction  of  its  vital  power,  it  was  incapable  of 
hearing  a similar  increase  of  action  as  the  other 
parts;  soon,  therefore,  after  the  use  of  the  cordial 
mixture  and  the  opium,  of  which  he  only  took  two 
grains,  it  felt,  to  use  the  patient’s  own  expression, 
“as  hot  as  if  on  fire.”  It  was  at  the  time  these 
medicines  were  administered,  in  a condition  nearly 
similar  to  that  of  a limb  benumbed  with  cold, — its 
vascular  action  was  much  depressed.  When  in 
this  state,  it  was  excited  to  a degree  which  over- 
powered its  feeble  energy,  just  as  would  have 
happened  by  suddenly  heating  a frost-bitten  mem- 
ber. 

In  the  Appendix  to  the  translation  of  Professor 
Scarpa’s  work,  by  Mr.  Wishart,  a case  will  be 
found,  which  corroborates  what  has  been  stated, 
respecting  the  induction  of  gangrene  by  vascular 
excitement.  The  case  to  which  I allude,  is  that 
of  Francis  Ballon.  This  case  is  introduced  by 
Mr.  Wishart,  as  illustrative  of  gangrene  occur- 


OF  THE  HEAD  AND  NECK. 


179 


ring,  because  the  anastomosing  arteries  did  not 
enlarge  to  a proper  degree,  to  carry  on  the  circu- 
lation. From  an  attentive  review  of  his  case,  it 
strikes  me,  that  in  it  the  gangrene  was  not  occa- 
sioned by  deficiency  of  circulation.  The  precur- 
sors of  sphacelation  were  not  such  as  would  have 
taken  place,  had  the  mortification  arisen  from  want 
of  blood. 

At  the  time  the  operation  was  performed,  the 
system  was  by  no  means  in  a very  favourable  state. 
The  symptoms  were  such  as  to  lead  one  to  suspect 
more  mischief  than  what  was  apparent.  M.  Mur- 
sina  says,  “the  general  health  of  the  patient  was 
not  very  unfavourable,  if  we  except  a slight  de- 
gree of  fever,  with  quickness  of  pulse  towards 
evening.”  Yet  such  a condition  I would  dread 
more  than  a regularly  formed  hectic.  The  latter, 
experience  has  shewn,  will  generally  disappear, 
when  we  remove  the  cause  which  kept  it  up;  but 
the  former  renders  the  result  of  any  operation  ha- 
zardous. It  is  a deceitful  and  insidious  affection, 
which  without  seeming  to  be  connected  with  any 
peculiarity  of  condition,  yet  really  accompanies  a 
state  of  body  which  is  most  unfavourable  for  ope- 
ration. The  patients  have  an  anxious  counte- 
nance, a sharpness  of  feature,  and  an  irritable 
quick  pulse;  symptoms,  which  still  continue  after 
the  operation,  and  which,  in  a few  days,  are  fol- 
lowed by  a sudden  alteration  for  the  worse.  Some- 
times the  patient  is  carried  off  by  an  irregular 


180 


ON  THE  SURGICAL  ANATOMY 


fever,  at  other  times  he  sinks  under  an  obstinate 
diarrhoea,  accompanied  with  pyrexia  and  delirium, 
or  is  worn  out  by  incessant  cough,  restlessness,  and 
want  of  appetite;  or  he  falls  a prey  to  local  gan- 
grene. I may  add,  that  I have  never  seen  any 
treatment  arrest  the  progress  of  the  disease. 

The  operation  on  Ballon,  performed  in  the  Hun- 
terian mode,  was  followed  by  the  usual  effect — re- 
duction of  the  temperature  of  the  part  below  the 
ligature.  Four  hours  had  just  elapsed,  when  the 
upper  part  of  the  leg  became  warm.  On  the  third 
day,  the  limb,  down  to  the  ankle  joint,  “was  warm: 
but  the  foot  was  cold,  though  not  without  feeling. 
The  skin  of  the  foot  was  shrivelled,  and  formed 
small  folds.”  Soon  he  complained  of  a burning 
pain  in  the  wound,  and  in  a short  time  an  equal 
and  moderate  heat  diffused  itself  over  all  the  limb, 
and  was  followed  by  a gentle  moisture.  The  folds 
on  the  foot  disappeared  as  the  heat  returned,  and 
pressure  on  the  veins  of  the  leg  produced  turges- 
sence  of  those  below.  These  facts  are  so  strong 
that  they  hardly  require  any  comment.  Do  they 
not  clearly  demonstrate,  that  the  circulation  was 
now  re-established  to  the  very  extreme  points  of 
the  limb?  Of  consequence  gangrene  was  not  now 
to  be  apprehended  from  deficiency  of  blood;  yet 
the  member  was  far  from  being  safe.  On  the  night 
between  the  fourth  and  fifth  day,  he  had  severe 
pain  in  the  limb,  following  the  course  of  the  ves- 
sels, and  extending  upward  toward  the  abdomen: 


OF  THE  HEAD  AND  NECK. 


181 


“the  pulse  at  the  same  time  was  small  and  quick, 
and  the  heat  very  great.”  By  a very  small  dose 
of  the  tinct.  opii,  twice  repeated,  the  symptoms 
were  removed,  “except  a burning  sensation  which 
began  in  the  knee,  and  extended  to  the  sole  of  the 
foot.”  Till  the  eleventh  day  the  patient  mend- 
ed; “all  the  toes  except  the  little  one  were  ex- 
tended, and  the  skin  covering  them  and  the 
foot  was  of  natural  colour,  and  warm.  But  to- 
wards evening  of  this  day,  the  back  of  the  foot 
began  to  swell,  and  the  colour  of  the  skin  be- 
came darker  than  before.  The  temperature  of 
the  extremity  icas  increased  at  this  place,  espe- 
cially inhere  the  toes  join  the  metatarsal  bones.'' 
This  fact  of  itself,  were  it  even  uncorroborated 
by  the  other  concomitant  circumstances,  would 
be  sufficient  to  establish  the  fact,  that  the  gan- 
grene, in  this  case,  was  not  induced  by  want  of 
blood.  Can  any  one  believe,  that  during  eleven 
days  the  limb  would  remain  without  circulation 
and  yet  shew  no  tendency  to  gangrene?  In  real- 
ity, if  the  cases  in  which  sphacelus  has  taken 
place  from  deficient  circulation,  be  reviewed,  it 
will  be  found  that  the  parts  have  never  reco- 
vered their  natural  heat;  and  it  will  also  be  ob- 
served, that  the  mortification  has  commenced 
very  shortly  after  the  operation.  Some  may 
say  that  instances  are  on  record,  in  which  mor- 
tification has  taken  place  from  want  of  blood, 
and  yet  where  the  parts  have  regained  their 


182 


ON  THE  SURGICAL  ANATOMA 


warmth  after  the  operation.  But  this,  in  so  far 
as  I can  learn,  has  only  happened  in  those  cases 
where  heated  applications  have  been  had  re- 
course to.  And  I think  I may  even  go  the 
length  of  saying,  that  in  these  cases,  so  soon  as 
the  substance  imparting  the  heat  has  been  re- 
moved, the  heat  itself  has  begun  to  be  dissipated, 
and  has  soon  been  altogether  lost.  I need  hardly 
add,  that  where  the  limb  receives  this  usage, 
although  it  might,  perhaps,  have  otherwise  es- 
caped, it  will  be  irretrievably  destroyed.  In  the 
case  of  Ballon  it  must  have  been  observed,  that 
the  heat  was  restored  by  operations  dependent 
on  the  vital  actions  of  the  parts,  and  the  limb 
survived  till  it  was  beyond  the  risk  of  gangrene, 
from  deficient  circulation: — His  case  might  serve 
for  that  of  the  last  patient,  for  the  result  was 
similar. 

Notwithstanding  the  use  of  spirituous  embroca- 
tions, and  watery  deeoctions  of  reputed  antiseptic 
herbs  to  the  limb,  and  the  internal  use  of  aroma- 
tic infusion  of  bark,  laudanum,  and  ether,  the 
gangrene  spread  to  the  tarsus;  but,  as  in  the 
case  which  occurred  to  myself,  the  slough  con- 
tinued superficial,  was  confined  to  the  back  of 
the  foot,  and  began  even  to  separate.  There 
was  in  neither  case,  from  the  extent  of  the  local 
affection,  any  reason  to  expect  a fatal  issue,  yet, 
in  both,  the  constitutional  symptoms  ran  so 
high  as  to  render  ultimate  recovery  altogether 


OP  THE  HEAD  AND  NECK. 


183 


out  of  the  question.  He  died  about  a month  after 
the  operation;  and  it  is  worthy  of  remark,  that 
from  the  first  to  the  last  the  toes  remained  free 
from  gangrene,  which  instead  of  beginning  at 
the  extreme  points,  as  it  would  have  done,  had 
it  been  dependent  on  impaired  circulation,  com- 
menced on  the  back  of  the  foot,  and  proceeded 
upward. 

These,  and  many  other  cases  on  record,  war- 
want,  I think,  the  conclusion,  that  after  the  ope- 
ration for  aneurism,  we  have  fully  as  much  to 
dread  from  over-excitement,  as  from  want  of 
blood.  They  also  incontrovertibly  prove,  that 
this  danger  is  not  at  an  end  so  soon  as  the  circu- 
lation is  fully  established  in  its  new  channel. 
The  limb  for  two  or  three  weeks  continues  in  a 
precarious  state.  The  immediate  risk  after  the 
operation,  is  from  want  of  blood;  an  event  which 
will  chiefly  happen  in  old  and  debilitated  pa- 
tients; such  as  no  intelligent  surgeon  would  ope- 
rate on.  After  this  source  of  danger  is  over, 
there  is  still  another  and  even  greater  to  be 
apprehended  from  excitement,  more  than  the 
limb  in  its  weakend  state  is  able  to  bear.  In  the 
latter  case,  the  plan  of  treatment  embraces  only 
a choice  of  difficulties;  what  the  most  judicious 
treatment  may  be,  remains  to  be  determined  by 
future  experience. 

Mr.  Charles  Bell,  in  his  System  of  Operative 
Surgery,  describes  another  species  of  gangrene 


184 


ON  THE  SURGICAL  ANATOMY 


consequent  to  the  operation  for  aneurism.  As 
I have  never,  however,  seen  a case  of  this  kind, 
I shall  transcribe  what  Mr.  B.  has  written  on 
this  subject.  When  treating  of  gangrene,  after 
the  operation  for  popliteal  aneurism,  he  says, 
“I  do  not  think  that  the  cure  of  it  is  gene- 
rally understood;  at  least,  in  the  only  two  in- 
stances which  I have  seen,  the  cause  was  one 
which  I do  not  recollect  to  have  seen  mentioned, 
viz.  the  inflammation  and  distension  consequent 
upon  the  suppuration  of  the  tumour  behind  the 
knee.  Where  the  tumour  has  been  small,  and 
the  oedema  slight,  I have  no  fear  for  the  re-estab- 
lishment of  the  circulation  of  the  limb;  but  when 
the  circulation  seems  perfectly  established  a few 
days  after  the  operation,  and  there  comes  great 
distension  about  the  knee,  and  the  tumour  in  the 
ham  becomes  large  and  firm,  when  the  oedema 
in  the  leg  and  foot  does  not  go  down,  and  there 
is  pricking  pain  shooting  to  the  toes,  with  a 
dark  colour  of  the  skin,  I conceive  there  is  dan- 
ger of  the  vesications  which  precede  gangrene, 
arising  on  the  toes.  This  gangrene  I have  seen 
proceed  in  its  course  uniformly  for  several  days, 
and  cease  upon  the  bursting  of  the  tumour  and 
the  discharge  of  the  blood  of  the  aneurism,  and 
a great  quantity  of  offensive  matter  from  behind 
the  joint,  and  from  under  the  bellies  of  the  gas- 
trocnemii.  The  tension,  as  I conceive,  occa- 
sioned by  the  inflammation  and  the  swelling 


OF  THE  HEAD  AND  NECK. 


185 


of  the  sac,  had  stifled  and  suppressed  the  free 
action  of  the  collateral  vessels,  and  the  return 
of  blood  by  the  veins,  so  as  to  produce  gan- 
grene in  the  extreme  parts.  Should  such  a case 
present  itself  to  me,  I should  have  no  hesitation  in 
puncturing  the  tumour  of  the  aneurism.  To  punc- 
ture it  in  this  stage,  after  inflammation  had  taken 
place  in  the  sac,  I should  imagine  would  be  atten- 
ded with  no  haemorrhage,  but  only  with  the  eva- 
cuation of  such  grumous  blood  as  flows  with  the 
matter  when  it  bursts  spontaneously  At  all 
events,  it  should  be  so  punctured  that  the  open- 
ing might  be  closed  again,  in  such  a way  as  to 
avoid  accelerating  the  wide  extending  suppura- 
tion which  sometimes  follows  the  dissolution  of 
the  blood  in  the  sac. 

“When  gangrene  has  taken  place,  from  what- 
ever cause,  and  here  as  in  others,  the  system 
must  be  supported.  The  countenance  and  pulse 
will  sufficiently  indicate  the  necessity  of  this. 
When  the  danger  is  warded  off,  the  extensive 
suppuration,  and  the  destruction  of  the  bones, 
both  from  the  matter  and  from  their  lying  pressed 
to  the  bed  by  the  weight  of  the  limb  will  endan- 
ger the  patient’s  life.  In  this  state,  we  must  still 
guard  the  general  health,  and  wait  for  an  oppor- 
tunity of  amputating.” 

Some  have  conjectured,  that  where  the  aneu- 
rismal  tumour  is  so  situated,  that  a ligature 
cannot  with  propriety  be  applied  around  the 
24 


186 


ON  THE  SURGICAL  ANATOMY 


artery,  nearer  to  the  heart  than  the  tumour, 
that  advantage  will  arise,  from  passing  one  on 
the  distal  side  of  the  sac.  This  is  not  a new 
opinion,  nor  does  it  now  remain  as  a matter  of 
conjecture.  It  has  actually  been  put  in  prac- 
tice, and  has  failed.  I cannot  conceive  a more 
futile  idea,  than  to  suppose  that  such  an  opera- 
tion could  possibly  tend  to  prevent  the  growth 
of  the  sac.  One  might  readily  believe,  that  it 
may,  by  preventing  the  blood  from  passing  freely 
through  the  tumour,  cause  it  to  enlarge  more 
rapidly  than  before.  That  it  would  occasion  a 
firm  coagulation  of  the  contents  of  the  aneurism, 
and  a consequent  enlargement  of  the  anastomo- 
sing branches,  and  diversion  of  the  blood  from  the 
tumour,  is  what  one  would  hardly  expect;  and 
least  of  all,  would  any  one  imagine  that  Desault 
would  have  been  the  projector  of  such  a doc- 
trine, and  Deschamps  the  first  to  put  it  to  the 
test  of  experiment.  In  doing  this,  the  latter 
had  no  reason  to  boast  of  his  dexterity,  nor 
could  he  say  more  of  his  success.  Others  who 
have  ventured  to  follow  his  example,  have  not 
obtained  a more  fortunate  result.  Indeed,  all 
circumstances  considered,  there  is  no  point  in 
the  treatment  of  aneurism,  which  ought  to  be 
more  decidedly  reprobated  than  this:  it  is  absurd 
in  theory,  and  experience  proves  that  it  is  ruinous 
In  execution. 


OF  THE  HEAD  AND  NECK. 


187 


Having  now  attended  to  the  cure  of  aneurism 
by  a surgical  operation,  and  having  also  pointed 
out  the  general  causes  of  failure,  arising  from  the 
direct  consequences  of  the  operation,  I may  next 
mention,  that  the  patient  is  sometimes  cut  off  by 
the  sudden  rupture  of  an  internal  aneurismal  tu- 
mour. This  would  render  it  a most  desirable  ob- 
ject with  the  surgeon,  to  be  able  to  discover 
whether  an  external  aneurism  was,  or  was  not 
complicated  with  an  internal  one;  but  the  truth 
is,  we  find  great  difficulty  in  detecting  the  exist- 
ence of  the  latter,  which,  when  present,  will  ma- 
terially influence  the  success  of  the  operation. 
Are  we,  therefore,  on  this  account  in  every  case, 
to  decline  an  operation,  or  how  are  we  to  pro- 
ceed? I think  the  only  answer  which  can  be 
given  to  this,  is  to  state  the  results  of  the  opera- 
tion in  a certain  number  of  cases,  and  to  reason 
from  the  facts  we  obtain.  This,  Mr.  A.  Cooper 
of  London,  had  the  goodness  to  communicate  to 
me,  for  insertion  in  an  Essay  on  Aneurism  of  the 
Thoracic  Aorta.  This  list  contains  the  opera- 
tions he  has  performed  for  the  cure  of  external 
aneurisms.  Their  results,  whether  successful 
or  the  reverse,  have  been  impartially  stated,  and 
the  causes  of  failure  mentioned.  This  detail  can- 
not, therefore,  fail  to  be  read  with  great  interest. 
It  is  intended  to  shew,  that  although  internal 
aneurism,  may,  in  some  patients,  be  conjoined 
with  external,  that  still  this  combination  is  by  no 


188 


ON  THE  SURGICAL  ANATOMY 


means  so  frequent  as  to  afford  any  reasonable  ob- 
jection to  the  performance  of  an  operation  for  the 
removal  of  the  latter.  The  fact  is,  that  unless 
where  an  operation  is  obviously  prohibited  by  the 
unequivocal  existence  of  an  internal  aneurism,  or 
by  that  febrile  state  which  renders  abortive  any 
operation,  we  are,  if  the  patient  be  otherwise  in  a 
favourable  condition,  to  attempt  the  cure  of  every 
external  aneurism,  by  operation.  If  the  operation 
prove  sometimes  unsuccessful,  from  the  rupture 
of  an  undiscovered  internal  aneurism,  this  cir- 
cumstance cannot  surely  be  brought  forward  as  an 
objection  to  the  operation,  or  be  laid  to  the  charge 
of  the  operator.  It  argues  no  neglect  or  defi- 
ciency on  his  part;  for  it  may  happen  in  the  prac- 
tice of  the  most  intelligent,  as  readily  as  in  that  of 
the  most  ignorant.  It  is  an  event  which  the  most 
consummate  knowledge  can  generally  neither  fore- 
see nor  prevent. 

Although  it  would  evidently  be  improper  to 
hazard  an  operation  in  a patient,  in  whom  there  ex- 
isted symptoms  characteristic  of  an  internal  aneu- 
rism, yet  I can  confidently  advise,  that  where 
other  circumstances  are  favourable  to  the  attempt, 
we  should  endeavour,  even  where  we  have  reason 
to  believe  that  the  aorta  is  aneurismal,  to  cure 
the  external  disease  by  compression.  This  advice 
is  only,  however,  applicable  to  aneurisms  seated 
about  the  extremities.  At  present,  I know  a 
gentleman,  who  during  some  months  watched  a 


OF  THE  HEAD  AND  NECK. 


189 


pulsating  tumour  in  his  ham,  which  was  slowly 
increasing  in  size,  and  imperceptibly  impairing 
the  motions  of  the  limb.  The  characters  of  aneu- 
rism were  so  decidedly  marked,  that  there  could 
be  no  hesitation  as  to  the  nature  of  the  disease. 
But  an  operation  was  thought  by  some  to  be  out  of 
the  question,  from  the  probability  of  the  patient’s 
having  some  affection  of  the  heart.  He  com- 
plained of  a difficulty  in  breathing  when  he  ex- 
erted himself,  and  he  was  liable  at  times  to  fits  of 
palpitation  of  the  heart,  and  unpleasant  sensations 
about  the  chest.  He  was  of  a full  habit  of  body, 
and  had  an  unhealthy  look.  Taking  these 
circumstances  into  consideration,  he  was  advised 
not  to  submit  to  an  operation.  He  was  directed  to 
live  sparingly,  to  keep  the  circulation  moderate, 
and  the  bowels  very  easy,  and  to  avoid  exertion. 
The  limb  was  rolled  in  a moderately  tight  ban- 
dage, from  the  toes  up  along  the  thigh,  the  pres- 
sure being  increased  at  the  knee  joint,  by  a 
compress  applied  over  the  tumour. 

By  persisting  in  this  treatment  for  a few 
weeks,  the  tumour,  which  had  never  been  larger 
than  a hen’s  egg,  became  prety  solid.  Ultimately 
it  became  perfectly  firm,  and  ceased  to  pulsate. 
During  the  progress  of  this  case,  the  leg  con- 
tinued to  receive  a due  supply  of  blood,  and  a 
new  course  was  established  for  the  circulation. 
An  artery  about  the  size  of  the  radial  could  now 
be  traced  along  the  tendon  of  the  semi-mem- 


190 


ON  THE  SURGICAL  ANATOMY 


branosus  muscle,  between  it  and  the  firm  tumour. 
A little  above,  and  a little  below  the  knee  joint, 
this  artery  ceased  to  be  distinguishable.  Its 
origin  and  termination  was  obscured  by  the  thick- 
ness of  the  part  which  cover  them,  but  no  one 
could  mistake  its  office. 

There  can  be  no  doubt  that  the  coagulation  of 
the  contents  of  the  sac  was  accelerated  by  the  band- 
aging; and  there  is  almost  a certainty  that  this  pa- 
tient will  never  experience  any  farther  inconve- 
nience from  this  tumour,  which  has,  in  fact,  no  con- 
nexion with  the  circulation,  which  is  performed 
altogether  independently  of  the  popliteal  artery. 
But  still  the  risk  is  imminent,  the  affection  of  the 
chest  is  not  removed,  neither  is  its  nature  ascer- 
tained. It  may  be  merely  sympathetic,  but  it  is 
to  be  feared  that  it  has  a more  serious  foundation. 
It  too  nearly  resembles  aortic  aneurism,  not  to  af- 
ford just  cause  for  apprehension.*  His  fate  may, 
perhaps,  be  similar  to  that  of  MacDonald,  operat- 
ed on  by  Mr.  Freer  of  Birmingham.  By  this  gen- 
tleman he  was  cured  of  an  inguinal  aneurism  on 
the  right  side.  Soon  afterwards  he  perceived  an 
aneurismal  tumour  in  his  left  ham.  This  also  was 
removed  by  an  operation  performed  by  Mr.  An- 
derson, in  the  Glasgow  Infirmary.  To  appear- 
ance the  patient  recovered  most  completely.  Con- 
trary, however,  to  instructions  given  him  on  quit- 

* This  gentleman  died  about  two  years  afterwards,  from  the  rupture  of 
an  aortic  aneurism.— Ed. 


OF  THE  HEAD  AND  NECK. 


191 


ting  the  hospital,  he  engaged  in  the  active  duties 
of  a game- keeper, — continued  to  improve  in  health 
and  strength;  but  suddenly  died,  while  leaping  a 
hedge  or  ditch,  from  the  bursting  of  an  abdominal 
aortic  aneurism. 

The  carotid  artery  seems  to  be  most  prone  to 
disease  at  the  point  where  it  bifurcates;  here  its 
“tissu  arteriel ” becomes  frequently  cartilaginous, 
or  earthy  matter  is  deposited  in  its  structure. 
This  weakens  the  artery,  and  paves  the  way  for 
rupture  of  the  internal  coat  and  “tissu  arteriel 
followed  by  dilatation  of  the  membranous  coat  and 
external  covering.  It  lays  the  foundation  of  aneu- 
rism, which  is  generally  seated  at  the  bifurcation 
of  the  carotid.  I have  repeatedly,  in  the  dead 
subject,  met  with  a dilatation  of  the  common  caro- 
tid and  root  of  the  internal  carotid,  forming  a cyst 
nearly  as  large  as  a filbert  nut,  and  I have  twice 
felt  a similar  state  of  the  vessel  in  the  living  body. 
In  some  of  the  former  cases,  the  texture  of  the  ar- 
tery was  altered,  but  in  most  of  them  the  dilata- 
tion had  taken  place,  independently  of  any  organic 
disease  of  the  coats.  In  the  two  instances  in  which 
the  artery  was  enlarged  in  the  living  subject,  the 
patients  experienced  no  inconvenience,  nor  for 
some  months,  during  which  I had  an  opportunity 
of  seeing  them,  did  the  dilatation  seem  to  advance. 

Till  lately,  aneurism  of  the  carotid  artery  was  a 
most  hopeless  disease.  Its  cure  is  a recent  inven- 
tion, which  is  calculated  to  impress  us  with  the 


192  ON  THE  SURGICAL  ANATOMY 


great  and  decided  superiority  of  modern  over  an- 
cient surgery.  The  experiments  of  Dr.  Thomp- 
son and  of  Dr.  Jones  had,  indeed,  paved  the  way 
to  improvement  in  the  treatment  of  this  species  of 
aneurism.  Their  observations  clearly  proved  the 
safety  of  including  the  carotid  artery  in  a ligature. 
They  intercepted  the  circulation  of  the  blood  along 
this  vessel,  yet  neither  the  brain  nor  any  other  part 
of  importance  suffered;  the  ligature  separated  as 
readily  and  as  easily  as  from  any  other  artery  of 
similar  size.  The  dread  of  the  thread  being  de- 
tached by  the  strong  action  of  the  vessel,  and  the 
vigorous  impulse  of  the  blood  against  it  from  the 
heart,  was  shewn  to  be  without  foundation.  The 
safety  and  practicability  of  tying  this  vessel  was 
established  on  the  sure  basis  of  actual  experiment. 
It  was  demonstrated  that  the  brain  would  be  fully 
nourished  by  the  vertebral  arteries,  assisted  by 
one  carotid,  a fact  which  had,  indeed,  before 
that  time,  been  ascertained  on  the  living  human 
subject. 

All  were  ready  to  admit, these  truths,  but  none 
had  the  resolution  to  act  on  them  in  aneurism  of 
this  vessel.  When  surgeons  were  thus  divided 
between  hope  and  fear,  an  accident  occurred,  by 
which  the  carotid  artery  was  wounded.  Mr. 
Abernethy  saw  the  patient,  and  although  the  cir- 
cumstances were  by  no  means  favourable,  still,  as 
affording  a chance  of  recovery,  he  tied  the  vessel. 
Shortly  afterwards  the  man  died,  from  the  exten- 


OF  THE  HEAD  AND  NECK. 


193 


sion  of  inflammation  to  the  membranes  of  the  brain. 
This  was  an  unfavourable  case,  and  the  result  of 
the  experiment  was  rather  against  its  repetition. 

When,  therefore,  Mr.  John  Bell  saw  a case  of 
aneurism  of  the  carotid  artery,  he  watched  its 
progress,  from  its  slight  beginning  to  its  ultimate 
and  dreadful  issue:  He  reasoned  about  the  pro- 
priety of  operation,  and  decided  on  its  expedien- 
cy, yet  allowed  the  period  for  operation  to  pass 
by,  without  having  made  any  bold  attempt  to  save 
the  life  of  the  patient.  He  left  her  to  die,  when 
worn  out  by  a painful  disease,  protracted  during 
the  space  of  six  weeks. 

Mr.  Astlev  Cooper  next  balanced  in  his  own 
mind  the  advantages  and  the  risk  of  an  operation. 
From  a careful  review  of  the  facts  on  record  re- 
garding ligature  of  the  carotid  artery  and  other 
large  vessels,  he  satisfied  himself  that  although 
the  danger  of  operation  was  great,  it  was  still  by 
no  means  equal  to  the  certain  fatality  of  the  dis- 
ease, if  left  to  run  its  course.  He  resolved,  if  he 
should  ever  be  called  to  a case  of  this  kind,  that 
he  would,  if  other  circumstances  were  favourable, 
without  delay  perform  an  operation;  for  hazard- 
ous as  he  knew  it  must  be,  he  was  convinced  that 
it  was  the  only  remaining  hope  of  the  patient. 
A case  soon  occurred.  He  carried  into  execution 
his  proposed  plan, — the  patient  died.  Yet  he 
was  not  discouraged;  he  persisted  in  his  purpose, 
and  in  the  end  had  the  pleasure  of  witnessing 
25 


194 


ON  THE  SURGICAL  ANATOMY 


his  efforts  crowned  with  success.  He  established 
on  indubitable  grounds,  the  propriety  of  having 
recourse  to  an  operation.  A review  of  the  cases 
in  which  an  operation  has  been  performed,  will 
convince  every  one  that  the  causes  of  failure  were 
not  such  as  to  affect  the  merits  of  the  operation. 
These  cases  are  to  be  found  described  in  the 
Medico  Chirurgical  Transactions,*  in  an  inau- 
gural dissertation  on  carotid  aneurism  by  Dr. 
Vose,f  and  in  the  London  Medical  Review'.^ 

In  no  operation,  is  a correct  knowledge  of  the 
locality  of  the  parts  concerned  more  indispensa- 
bly necessary,  than  in  the  case  under  considera- 
tion If  the  situation  of  the  carotid  artery,  in 
the  different  divisions  of  the  neck,  he  remember- 
ed, it  will  he  evident  that  the  difficulty  in  expos- 
ing and  securing  that  vessel  will  he  greater  or  less, 
according  to  the  part  we  select.  Above  the  point 
of  decussation  of  the  omo-hyoideus  and  the  ster- 
no- mastoid  muscles,  the  artery  is  easily  reached. 
Unfortunately,  however,  it  happens,  that  in  an 
aneurism  of  the  carotid  artery,  especially  if  the 
disease  he  in  any  degree  advanced,  the  sac  de- 
scends so  low  in  the  neck  that  we  are  obliged  to 
take  up  the  artery  nearer  to  the  clavicle  than  this 
point.  Here  the  vessel  is  with  more  difficulty 
got  at,  it  lies  deeper,  and  is  now  more  closely 

* Medic.  Chirurgical  Transactions,  vol.  1st. 

t Disputatio  Pathologica  do  Arterise  Carotidis  Aneurismate.  Jacobus 
Vose,  Edin.  1809. 

| London  Medical  Keview,  No.  5,  p.  96. 


OF  THE  HEAD  AND  NECK. 


195 


connected  with  other  important  parts.  Instead 
of  having  only  to  divide  the  skin,  platysma  myoi- 
des,  and  fascia,  we  have  to  dissect  back  the  ster- 
nal head  of  the  sterno- mastoid  muscle,  which,  by 
its  inclination  forward,  covers  the  carotid  artery 
at  the  lower  part  of  the  neck.  Nor  is  this  the 
only  muscle  we  require  to  displace,  the  sterno- 
thyroideus  must  also,  in  some  measure,  be  drawn 
in  front  of  the  trachea,  before  the  sheath  of  the 
artery  is  brought  into  view. 

When  these  muscles  have  been  turned  aside,  the 
sheath  which  contains  the  jugular  vein,  the  caro- 
tid artery,  and  the  nervus  vagus,  must  be  cau- 
tiously opened.  This  is,  sometimes,  not  to  be  ac- 
complished without  considerable  difficulty.  When 
this  is  executed,  the  next  point  is  to  separate, 
along  a small  space,  the  artery  from  the  parts  in 
the  vicinity.  The  size  and  density  of  the  nervus 
vagus  render  the  separation  of  it  from  the  artery 
safe,  but  the  detachment  of  the  jugular  vein  is  not 
equally  easily  accomplished.  During  inspiration 
it  falls  collapsed,  but  during  expiration  it  swells 
out  full  and  tense,  covering  almost  completely  the 
front  of  the  artery.  The  transitions  from  empti- 
ness to  fullness  are  so  rapid,  that  sufficient  time  is 
not  allowed  to  detach  it  from  the  carotid.  The 
operator,  therefore,  feels  a considerable  difficulty 
in  this  part  of  the  operation;  prudence  and  dex- 
terity are  both  required  to  enable  him  to  finish  it.* 


See  Appendix,  (C.) 


196 


ON  THE  SURGICAL  ANATOMY 


Although  this  difficulty  be  perplexing,  yet  there  is 
another  species  of  danger,  which,  because  less  ap- 
parent, has  been  less  insisted  on. 

The  jugular  vein  is  evident  from  its  size,  and 
from  the  colour  of  its  contents;  injury  of  it  may, 
therefore,  be  generally  avoided.  Besides,  its  of- 
fiee  is  not  so  important  but  that  it  may  be  dispens- 
ed with.  We  would  notwithstanding  carefully 
avoid  injury  of  this  vein,  but  if  we  did  happen  to 
hurt  it,  experience  teaches  us,  that  the  event 
would  not  influence  the  success  of  the  operation. 
The  firmness  of  the  nervus  vagus  is  its  protection, 
while  the  close  connexion  of  the  sympathetic  nerve 
with  the  spine  guards  it  from  injury.  When,  how- 
ever, the  operation  is  performed  low  in  the  neck 
on  the  left  side,  the  termination  of  the  thoracic 
duct  is  not  so  secure.  It  lies  just  behind  the  ca- 
rotid, interposed  between  its  sheath  and  the  sym- 
pathetic nerve,  and  in  some  subjects,  it  mounts 
pretty  high  in  the  neck,  before  it  curves  down- 
ward and  outward,  to  join  the  subclavian  vein. 
We  would  most  carefully  avoid  injury  of  this  ves- 
sel, yet  its  position  exposes  it  to  be  hurt. 

The  nerves,  if  cut,  will  reunite,  and  the  vein, 
if  injured,  will  transfer  its  circulation  to  some  of 
the  collateral  branches;  but  the  thoracic  duct  is 
a vessel  for  which  there  is  no  substitute.'*  Its 

* The  lacteals  generally  anastomose  with  the  lymphatics  of  the  liver  and 
diaphragm,  so  th  t even  where  the  thoracic  duct  has  been  obstructed,  the 
chyle  has  continued  to  find  its  way  into  the  blood;  but  this  is  no  argument 
against  the  general  assertion,  that  the  thoracic  duct  is  a vessel  for  which 
‘here  is  no  substitute. 


OF  THE  HEAD  AND  NECK.  197 

function  cannot  be  dispensed  with;  it  must  be 
avoided,  yet  its  proximity  to  the  artery  is  such, 
that  a rash  operator  may  tear  it  asunder,  while 
detaching  the  carotid  from  its  connexions.  It 
is  of  small  size;  its  coats  are  thin  and  transpa- 
rent; and  it  is  only  after  a good  meal,  that  its 
canal  is  filled  with  a white  fluid.  The  surgeon 
has,  therefore,  no  monitor,  except  his  previously 
acquired  knowledge,  regarding  the  locality  of 
the  duct,  which  will  teach  him  to  keep  as  much 
in  contact  with  the  coats  of  the  vessel  on  the 
back  part,  as  possible.  A precaution  equally 
required,  to  prevent  injury  of  the  sympathetic 
nerve,  and  nervus  superficialis  cordis,  as  of  the 
thoracic  duct. 

It  is  also  necessary  to  remember,  that  there 
may  be  two  arteries  low  in  the  neck.  In  a fe- 
male child,  I lately  found  the  left  vertebral  artery 
rising  from  the  arch  of  the  aorta.  On  the  right 
side  of  the  same  subject,  the  vertebral  artery 
originated  from  the  subclavian,  along  side  of  the 
carotid  artery,  behind  which  it  suddenly  insinua- 
ted itself.  It  afterwards  ascended  along  the 
surface  of  the  rectus  major  anticus,  attached  to 
the  sympathetic  nerve,  till  it  reached  the  third 
cervical  vertebra.  At  this  part  of  the  neck,  just 
a few  lines  below  the  bifurcation  of  the  carotid, 
the  vertebral  artery  entered  the  vertebral  canal. 
The  artery  lay  exterior  to  the  sheath  of  the  cer- 
vical vessels  and  nerves;  but  in  its  whole  course 


198 


ON  THE  SURGICAL  ANATOM! 


ran  parallel  to,  and  immediately  behind  the  com- 
mon  carotid  artery.  It  was  nearly  as  large  as 
the  barrel  of  a goose  quill. 

I consider  this  to  be  an  important  variety  in 
the  distribution  of  the  cervical  vessels.  It  is  one, 
which  the  surgeon  ought  never  to  lose  sight  of, 
while  operating  about  the  neck.  In  taking  up 
the  carotid  artery,  it  might  have  embarrassed 
him,  for  it  was  only  separated  from  the  carotid, 
by  the  thin  interposed  sheath.  We  have  full 
proof  that  the  carotid  artery  may  be  tied,  with- 
out impairing  the  functions  of  the  brain;  but  we 
have  no  testimony  that  this  organ  will  continue 
to  discharge  its  actions,  if  the  carotid  and  verte- 
bral arteries  on  one  side  be  both  included  in  a 
ligature.  In  passing  the  thread,  therefore,  round 
the  carotid,  care  ought  to  be  taken,  not  to  carry 
it  behind  the  sheath,  because,  while  the  liga- 
ture is  kept  between  the  artery  and  the  sheath, 
neither  the  end  of  the  thoracic  duct,  nor  the  sym- 
pathetic nerve,  nor  the  superficial  nerve  of  the 
heart,  nor  the  vertebral  artery,  can  possibly  be 
included. 

There  is  also  another  object  in  remembering 
this  anomally  of  the  vertebral  artery.  Had  this 
vessel  become  aneurismal,  the  tumour  produced, 
would,  in  almost  every  point,  and  in  every  essen- 
tial character,  have  resembled  carotid  aneurism. 
The  surgeon,  deceived  into  a belief,  that  the 
disease  was  seated  in  that  vessel  might  have 


OF  THE  HEAD  AND  NECK. 


199 


taken  it  up;  but  his  astonishment  would  have 
been  great,  when  he  discovered  that  tightening 
the  ligature  made  no  impression  on  the  sac;  that 
it  still  continued  to  pulsate  with  equal  vigour  as 
before,  and  was  in  no  degree  diminished  in  size. 
When,  therefore,  the  surgeon  has  reached  the 
sheath  of  the  vessels,  he  ought,  uniformly,  before 
opening  it  to  press  the  carotid  between  the  finger 
and  thumb.  If  the  pulsation  of  the  tumour  be  not 
in  this  way  affected,  he  will  do  well  to  pause 
before  he  pass  a ligature  around  that  vessel.  A 
new  operation  would  be  required,  to  interrupt 
the  circulation  along  the  vertebral  artery. 

Although  this  be  altogether  supposititious,  still 
the  occurrence  is  within  the  range  of  probability; 
what  the  result  would  be,  no  man  can  predict. 
Let  not,  therefore,  any  operator  forget  that  he 
may  meet  with  a similar  arrangement  of  the  ves- 
sels, while  operating  on  the  living  subject;  neither 
let  it  escape  his  recollection,  that  unless  the  na- 
ture of  the  complaint  be  carefully  ascertained,  he 
will  probably  require  to  intercept  the  course  of 
the  blood,  along  two  of  the  large  arteries  belong- 
ing to  the  brain. 

In  aneurism  of  the  carotid  artery,  it  is  like- 
wise proper  to  remember,  that  the  common  ca- 
rotid artery  sometimes  divides  into  its  external 
and  internal  trunks,  very  low  in  the  neck,  even 
opposite  to  the  sixth  vertical  vertebra.  Now 
it  is  demonstrable,  that  were  one  of  these  vessels 


200  ON  THE  SURGICAL  ANATOMY 


becoming  aneurismal,  there  would  be  no  neces- 
sity? and  therefore  no  propriety,  in  taking  up 
both;  neither  would  it  be  necessary  or  proper  to 
tie  the  common  trunk,  unless  where  the  disease 
was  seated  so  low  as  to  require  it.  I cannot 
point  out  any  character  by  which  it  may  be  as- 
certained? before  beginning  the  operation?  that 
there  are  two  arteries  in  the  neck;  but  I think 
that  a surgeon  who  is  aware  of  the  possibility  of 
such  an  occurrence,  may  discover  it  by  pressing 
the  vessel  between  the  finger  and  thumb  before 
tying  it. 

Jn  regard  to  the  general  treatment?  previous 
to,  and  after  the  operation,  much  will  not  require 
to  be  said.  Where  the  patient  is  young  and  ple- 
thoric? with  the  constitution  unbroken,  it  will 
be  prudent  to  reduce  the  strength  before  opera- 
ting? by  occasional  bleeding,  conjoined  with 
purging  and  spare  diet.  After  operating?  the 
surgeon  is  to  enjoin  the  strictest  rest?  is  to  avoid 
carefully  whatever  has  a tendency  to  accelerate 
the  circulation?  and  is  only  to  allow  the  lightest 
and  most  digestible  food.  In  fact?  the  most 
rigid  antiphlogistic  regimen  is  to  be  followed 
out?  and  whenever,  notwithstanding  this?  we 
perceive  any  tendency  to  increased  action,  pur- 
gatives are  to  be  employed.  Invariably  the 
bowels  are  to  be  kept  easy,  and  rather  open? 
which  may  be  done  by  proper  attention  to  diet 
and  the  frequent  use  of  stewed  fruits?  or  by 


OF  THE  HEAD  AND  NECK. 


201 


employing  a solution  of  the  super- tartrite  of  potass 
for  common  drink. 

Where  an  anodyne  has  been  required  after  an 
operation  for  aneurism,  I have  preferred  hyos- 
cyamus,  provided  it  did  not  disagree  with  the 
stomach. 

I have  very  little  to  say  concerning  the  mode  of 
performing  the  operation  of  tying  the  carotid  ar- 
tery. The  patient,  seated  on  a chair,  is  to  recline 
his  head  on  the  breast  of  an  assistant,  standing  be- 
hind him.  Then  the  surgeon  begins  as  far  below 
the  tumour,  as  shall  leave  a space  of  two  inches  at 
least,  in  which  to  cut  between  the  commencement 
of  his  incision  and  the  clavicle.  At  the  first  stroke 
of  the  scalpel,  he  is  to  cut  through  the  skin  and 
platysma  myoides,  then  he  is  to  divide  the  fascia 
along  the  course  of  the  anterior  margin  of  the 
sterno-mastoid  muscle.  When  this  muscle  is  ex- 
posed, he  is  to  dissect  beneath  it,  turning  it  out- 
ward till  he  reach  the  outer  margin  of  the  sterno- 
thyroid muscle.  He  is  then  to  raise  that  muscle, 
in  doing  which,  he  will  divide  the  filaments  of  the 
descendens  noni  which  pass  into  it.  By  a blunt 
hook,  the  sterno-mastoid  muscle  is  to  be  pulled 
aside  along  with  the  omo-hyoideus,  toward  the 
acromion,  while,  by  a similar  instrument,  the 
sterno-hyoid  and  thyroid  muscles  are  to  be  drawn 
over  the  trachea.  By  this  displacement  of  the 
muscles,  the  common  sheath  of  the  carotid  artery, 
internal  jugular  vein,  and  nervus  vagus  will  be 
26 


202 


ON  THE  SURGICAL  ANATOMY 


exposed.  On  the  tracheal  side  of  the  sheath,  if  the 
operation  be  performed  on  the  left  side,  the  oeso- 
phagus will  be  brought  into  view,  covered  by  the 
filaments  of  the  recurrent  nerve;  on  either  side, 
the  nervus  descendens  noni  will  be  seen  lying  on 
the  fore  part  of  the  sheath.  A finger  is  now  to  be 
employed  to  press  aside  the  jugular  vein,  after 
which,  the  sheath  is  to  be  scratched  through  ex- 
actly over  the  carotid  artery,  till  a director  can 
be  introduced  between  them.  Along  the  director, 
the  sheath  is  to  be  opened,  avoiding  in  doing  this, 
injury  of  the  trunk  of  the  nervus  descendens  noni. 

When  the  sheath  is  opened  to  the  extent  of 
about  three-fourths  of  an  inch,  the  handle  of  a 
scalpel  is  to  be  insinuated  between  the  artery  and 
the  jugular  vein,  retaining  it  as  closely  as  possible 
in  contact  with  the  former.  By  pressing  it  gently, 
but  steadily  forward,  and  by  moving  it  slightly  up- 
ward and  downward,  while  the  vein  is  flaccid,  and 
desisting  while  it  is  tense,  the  artery  will  soon  be 
detached  from  its  connexion  with  the  neighbour- 
ing parts  on  that  side.  By  similar  means  it  is  to 
be  separated  from  its  adhesions  on  the  tracheal 
side.  In  accomplishing  this,  neither  violence  in 
thrusting  forward  the  handle  of  the  scalpel,  nor 
rudeness  in  pulling  outward  the  artery  from  its 
sheath,  are  to  be  permitted.  The  former  may  in- 
jure the  thoracic  duct,  the  latter,  to  a certainty, 
will  destroy  the  vascular  adhesions  of  the  artery 
above  and  below  the  part  where  the  threads  are 


OF  THE  HEAD  AND  NECK. 


203 


io  be  tied,  and  will  thus  lay  the  foundation  of  in- 
flammation, suppuration,  and  secondary  haemorr- 
hage. 

When  about  half  an  inch  of  the  artery  is  com- 
pletely insulated,  the  handle  of  the  scalpel  is  to  be 
withdrawn,  and  an  aneurismal  blunt  needle,  armed 
with  a small,  firm,  and  round,  double  ligature, 
is  to  be  passed  beneath  the  vessel,  care  being 
at  the  same  time  taken,  not  to  include  any  of  the 
nerves.*  The  ligatures  are  next  to  be  sepa- 
rated, and  one  of  the  threads  is  immediately  to  be 
tied  as  low  down  as  the  artery  has  been  detached 
from  its  connexions,  and  the  other  is  to  be  tight- 
ened as  high  up.  There  will  thus,  where  the  ope- 
ration has  been  properly  performed,  be  about  half 
an  inch  of  the  vessel  intercepted  between  the  liga- 
tures. If  more  of  the  artery  be  intercepted,  I 
would,  for  reasons  stated  in  the  general  observa- 
tions on  aneurism,  be  inclined  to  remove  a part  of 
it.  This  is  not,  however,  material,  where  a small 
portion  has  been  intercepted  between  the  threads, 
especially,  since  it  has  been  proved  by  Mr.  A. 
Cooper,  that  it  is  perfectly  safe  to  leave  the  vessel 
without  dividing  it  in  the  interspace. 

So  soon  as  the  ligatures  are  tied,  and  one  end  of 
each  removed,  the  lips  of  the  wound  are  to  be 

* In  passing  the  ligatures,  a needle  made  of  unalloyed  silver  is  to  be  em- 
ployed. Its  flexibility  is  greater  than  when  mixed  with  any  other  metal. 
Now,  the  chief  difficulty  in  conveying  the  thread  round  the  vessel,  arises 
from  the  needle  not  bending  easily;  but  by  using  a needle  of  pure  silver, 
this  is  considerably  obviated.  Mr.  Abernethy  has  recommended  its  use. 


204 


ON  THE  SURGICAL  ANATOMY 


brought  into  contact,  and  retained  so  by  strips  of 
adhesive  plaster.  The  neck  is  then  to  be  lightly 
dressed,  and  the  patient  removed  to  bed.  There, 
to  avoid  putting  the  artery  on  the  stretch,  when  it 
has  not  been  divided  between  the  ligatures,  which 
ought  generally  to  be  done,  it  will  be  advisable  for 
him  to  lie  with  his  head  raised,  and  his  chin  in- 
clined to  his  breast. 

The  preceding  remarks  on  the  mode  of  operat- 
ing, have  been  delivered  from  the  experience  ob- 
tained from  trials  made  on  the  dead  subject,  and 
from  the  descriptions  of  the  operations  which  have 
been  performed  on  the  living  body.  As  I have  ne- 
ver myself  had  an  opportunity  of  performing,  or  of 
seeing  this  operation  performed,  except  on  an  infe- 
rior animal,  I shall  offer  no  apology  for  transcribing 
one  of  Mr.  Astley  Cooper’s  cases.  It  will  illustrate 
the  nature  of  the  disease,  the  way  in  which  the 
operation  was  performed,  and  the  after-treatment. 

“Humphrey  Humphreys,  aged  fifty,  who  has 
been  employed  to  carry  loads  of  iron*  as  a porter, 
observed  six  or  seven  months  ago,  a tumour,  hav- 
ing a pulsatory  motion,  and  about  the  size  of  a 
walnut,  on  the  left  side  of  the  neck,  just  under  the 
angle  of  the  jaw,  and  extending  from  thence  down- 
wards to  the  thyroid  cartilage.  It  was  accompa- 
nied with  great  pain  on  the  left  side  of  the  head, 

* “The  employment  consists  in  this: — A collar  of  -wood  is  placed  around 
the  neck  and  upon  the  shoulders,  and  he  carries  bars  of  iron  on  each  shoul- 
der thus  protected.” 


OP  THE  HEAD  AND  NECK. 


205 


which  began  about  five  months  ago,  and  was  at- 
tended with  a sense  of  pulsatory  motion  in  the 
brain.  The  tumour  affected  his  speech,  so  as  to 
make  him  extremely  hoarse;  and  he  had  more  re- 
cently a cough,  attended  with  slight  difficulty  of 
breathing,  and  which  seemed  to  be  the  effect  of 
the  pressure  on  the  swelling  of  the  larynx.  His 
appetite  was  sometimes  affected  by  it;  for  three  or 
- four  days  he  eat  heartily,  and  then  for  many  lost 
his  relish  for  food.  He  had  a sense  of  coldness, 
succeeded  by  heat  in  his  left  ear,  and  he  often  be- 
came sick  when  eating,  but  did  not  vomit.  Upon 
attempting  to  stoop  at  any  time,  from  that  period 
he  had  an  insupportable  feeling,  as  if  his  head 
would  burst;  a giddiness,  loss  of  sight,  and  almost 
total  insensibility. 

“The  left  eye,  which  had  for  some  time  been 
gradually  closing,  appeared  now  not  half  as  large 
as  the  right;  yet  its  power  of  vision  was  equally 
perfect. 

“A  blister  was  at  thU  time  ordered  to  be  ap- 
plied on  the  head  by  Dr  Hamilton,  which  lessen- 
ed his  pain.  A month  ago  he  applied  another 
with  the  same  relief,  but  it  lasted  only  for  a few 
days.  He  continued  to  work  until  the  day  previ- 
ous to  the  operation. 

“The  dilatation  of  the  carotid  artery  was  seated 
just  below  the  angle  of  the  jaw,  and  about  the 
acute  angle,  which  is  made  by  the  great  division 
of  the  common  carotid.  The  tumour  was  about 


206 


ON  THE  SURGICAL  ANATOMY 


the  size  of  a pullet’s  egg,  and  prominent  in  its 
middle. 

“The  pulsation  of  the  aneurism  on  the  day  of 
the  operation  was  remarkably  strong.  When  the 
sac  was  emptied  by  pressure  on  the  artery  below, 
the  tumour  sprang  to  its  original  size  with  one 
contraction  of  the  heart. 

“I  proposed  to  tie  the  common  carotid  below 
the  dilated  part,  and  the  operation  was  performed 
at  one  o’clock,  on  the  twenty-second  of  June,  1808, 
at  Guy’s  Hospital. 

“1  began  my  incision  opposite  the  middle  of 
the  thyroid  cartilage  from  the  base  of  the  tumour, 
and  extended  it  to  within  an  inch  of  the  clavicle 
on  the  inner  side  of  the  sterno-mastoid  muscle. 
On  raising  the  margin  of  this  muscle,  the  omo- 
hyoideus  could  be  distinctly  seen,  crossing  the 
sheath  of  the  vessels,  and  the  nervus  descendens 
noni  was  also  exposed.  I next  separated  the 
mastoid  from  the  omo-hyoideus  muscle,  and  the 
jugular  vein  became  apparent,  which,  being  dis- 
tended at  every  expiration,  spread  itself  over  the 
artery.  Drawing  aside  the  vein,  the  par  vagurn 
was  evident,  lying  between  it  and  the  carotid  ar- 
tery, but  a little  to  its  outer  side.  This  nerve 
was  easily  avoided. 

“A  blunt  iron  probe,  constructed  for  the  pur- 
pose, was  then  passed  under  the  artery,  carrying 
a double  ligature  with  it.  Two  ligatures  being 
thus  conveyed  under  the  artery,  the  lower  was 


OF  THE  HEAD  AND  NECK. 


207 


immediately  tied.  I next  detached  the  artery 
from  the  surrounding  parts,  to  the  extent  of  an 
inch  above  the  lower  ligature,  and  then  tied  the 
upper.  Lastly,  a needle  and  thread  were  passed 
through  the  artery,  above  one  ligature,  and  below 
the  other.  The  division  of  the  artery  was  then 
performed. 

“Nothing  now  remained  but  to  dress  the  pa- 
tient, and  this  was  done  by  drawing  the  parts 
together  by  adhesive  straps,  the  ligature  hang- 
ing from  each  end  of  the  wound,  and  by  laying 
on  a piece  of  lint  retained  by  straps  of  adhesive 
plaster. 

“Mr.  Vose,  my  dresser,  whose  attention  to 
the  case  was  unremitted,  and  to  whose  care 
and  knowledge  many  of  my  patients  have  been 
indebted  for  their  recovery,  now  asked  the  pa- 
tient if  he  experienced  any  unusual  sensations 
about  the  head.  He  answered,  that  for  the  first 
time,  since  two  months  after  the  formation  of 
the  tumour,  he  was  relieved  from  a distressing 
pain,  which  extended  up  the  left  temple,  accom- 
panied by  a violent  throbbing  of  all  the  arteries 
of  that  side. 

“The  pulsation  in  the  tumour  had  not,  how- 
ever, entirely  ceased,  although  it  was  so  much 
diminished  as  to  become  obscure;  but  it  was 
felt  by  my  colleague,  Mr.  Forster,  by  Mr. 
George  Young,  Mr.  Dubois,  jun.  from  Paris, 
who  accompanied  Mr.  Young,  by  Dr.  de  Sousa, 


208 


ON  THE  SURGICAL  ANATOMY 


and  many  others  who  were  present  at  the  opera- 
tion. I concluded  it  to  be  the  effect  of  the  re- 
turn of  blood  by  the  internal  carotid  artery,  from 
the  brain,  in  consequence  of  the  free  anastomosis 
which  exists  between  the  blood  vessels  within  the 
skull. 

“The  patient  was  put  to  bed  with  his  head 
elevated,  and  in  this  condition  he  felt  quite  com- 
fortable. 

“Three,  p.  m.  Pulse  was  moderate,  skin  cool, 
suffered  very  little  pain.  Pulsation  in  the  tumour 
perceptible,  but  inconsiderable,  when  contrasted 
with  its  force  before  the  vessel  was  tied. 

“Five,  p.  m.  Pulse  stronger  and  fuller,  but  in 
other  respects  as  before;  head  entirely  free  from 
pain. 

“Eight,  p.  m.  Patient’s  pulse  reduced  to  the 
healthy  standard,  skin  cool;  says  he  feels  no  pain. 

“June  23d. — Six,  a.  m.  Patient  passed  a good 
night. 

“One,  p.  m.  I saw  the  patient,  he  had  a slight 
cough;  has  had  no  evacuation  since  the  operation; 
pulse  was  not  quicker  than  natural. 

“Ten,  p.  m.  The  patient  got  out  of  bed  and 
went  to  the  water  closet,  and  had  an  evacuation. 

“June  24th. — Six,  a.  m.  Pulse  natural;  pulsa- 
tion in  the  tumour  continues;  tumour  sore  when 
compressed;  has  become  firm,  for  the  blood  which 
was  fluid  in  it  prior  to  operation,  and  all  yester- 


OF  THE  HEAD  AND  NECK. 


209 


day,  is  now  coagulated;  pain  and  a sense  of  full- 
ness felt  on  the  right  side  of  the  head. 

“June  25th. — Six,  a.  m.  Patient  says  he  no 
longer  feels  pain  in  any  part;  has  had  a good 
night;  has  only  one  troublesome  symptom,  viz.  an 
occasional  rattling  in  the  larynx,  from  accumu- 
lated mucus;  pulse  this  morning  quite  temperate. 

“Three,  p.  m.  The  tumour  is  considerably 
diminished;  pulse  moderate;  no  constitutional  irri- 
tation. 

“June  26th. — Eight,  a.  m.  Patient  had  a good 
night;  pulse  still  moderate;  skin  cool. 

“Eleven,  p.  m.  Still  free  from  any  disagreeable 
symptom. 

“June  27th. — Seven,  a.  m.  Patient  very  rest- 
less during  the  night;  coughed  much,  and  had 
pain  in  the  head;  spirits  depressed;  pulse  natural. 

“Half-past  one,  p.  m.  Pulse  eighty-four;  feels 
much  better  than  in  the  morning;  has  had  an 
evacuation  from  the  bowels  since  last  night. 

“June  28th. — Seven,  a.  m.  Pulse  natural;  had 
a tolerable  night;  bowels  open;  no  pain. 

One,  p.  m.  I saw  the  patient;  pulse  eighty-four; 
slight  pulsation  still  to  be  felt  in  the  tumour, 
which  is  much  diminished. 

“June  29th. — Pulse  natural,  no  pain;  pulsation 
still  perceptible;  tumour  so  much  less  that  the 
skin  is  wrinkled  over  it. 

“June  30th. — Wound  dressed  the  first  time; 
27 


210 


ON  THE  SURGICAL  ANATOMY 


and  has  united  by  the  first  intention,  as  far  as  the 
ligatures  would  permit;  he  is  free  from  irritation. 

“July  1st. — Pulse  natural;  man  tranquil;  pulsa- 
tion very  obscure;  tumour  firm;  he  is  very  hoarse. 

“July  2d. — No  stool;  ordered  opening  medi- 
cine; very  hoarse,  so  as  to  speak  only  in  a loud 
whisper. 

“July  3d. — Pulsation  doubtful;  man  healthy. 

“July  4th — Going  on  well. 

“July  5th. — Wound  looks  well;  man  appears 
natural;  but  the  hoarseness  continues. 

“July  6th. — He  is  free  from  any  symptoms  of 
irritation. 

“July  8th. — Patient  says  the  tumour  is  now 
only  half  its  size  at  the  time  of  the  operation. 

“July  ‘.tth. — Ordered  a poultice. 

“July  12th. — Ligature  projecting  more;  and 
much  more  discharge  from  the  wound. 

“July  14th. — Upper  ligature  came  away,  being 
removed  by  Mr.  Vose. 

“July  15th. — Lower  ligature  came  away;  pul- 
sation very  obscure. 

“July  17th. — Man  walked  out  of  his  ward; 
the  tumour  at  this  period  was  reduced  to  less 
than  half  its  size.  The  pulsation  in  it  was  with 
difficulty  perceived;  but  it  continued  until  the 
beginning  of  September;  at  which  period  all  who 
saw  him  agreed  that  the  pulsation  had  ceased, 
and  the  tumour  was  then  scarcely  apparent.  The 


OF  THE  HEAD  AND  NECK. 


211 


fascial  and  temporal  arteries  on  the  left  side  can- 
not  be  felt. 

“The  wound  was  a long  time  in  healing:  first, 
from  a sinus  in  the  course  of  the  ligatures,  and 
afterward  from  a fungus  where  the  sinus  had 
been  placed. 

“The  man  was  discharged  sound  on  the  14th 
day  of  September,  and  returned  to  the  occupation 
of  a porter,  at  Crawshay’s  Iron  wharf,  Thames- 
street. 

“Near  eight  months  have  now  elapsed  since 
the  operation  was  performed,  and  he  has  return- 
ed to  his  former  employment,  without  any  dimi- 
nution of  his  mental  or  corporeal  powers,  except 
the  lessened  action  of  the  temporal  and  fascial 
arteries  on  the  side  on  which  he  was  operated. 
The  tumour  has  disappeared,  and  he  has  not 
been  since  subject  to  that  pain  in  the  head,  by 
which  he  had  been  so  much  distressed  prior  to  the 
operation.5’* 


I have  now  attended  to  the  relation  of  the  dif- 
ferent parts  at  the  side  of  the  neck,  from  the  cla- 
vicle up  to  the  lower  border  of  the  digrastic 
muscle;  but  I have  still  to  consider  the  situation 


* Medico  Chirurgical  Transactions,  vol.  1.  page  224,  et  seq. 


212 


ON  THE  SURGICAL.  ANATOMY 


and  connexions  of  the  thyroid  gland.  At  pre- 
sent, 1 am  only  to  inquire  into  the  structure, 
connexions,  and  relations  of  this  organ  in  the 
adult,  in  so  far  as  these  tend  to  illustrate  the 
diseases  of  this  gland,  or  to  explain  their  effects. 
When  I afterwards  come  to  treat  of  the  confor- 
mation of  the  neck,  in  the  young  subject,  I shall 
have  occasion  to  notice  some  other  points  con- 
cerning the  locality  of  the  thyroid  gland  in  the 
early  part  of  life,  and  likewise,  to  deduce  from 
the  facts  to  be  then  st  ted,  some  practical  conclu- 
sions regarding  the  performance  of  the  operation 
of  bronchotomy. 

The  thyroid  gland  is  a firm  reddish-looking 
substance,  bearing  a considerable  resemblance  in 
its  outward  appearance,  to  the  conglobate  glands 
in  the  early  period  of  life,  which,  together  with 
its  containing  a number  of  lymphatics,  has  led 
some  to  conjecture,  that  it  belonged  to  that  sys- 
tem. Internally,  numerous  ramifications  of  arte- 
ries, veins,  and  absorbents,  are  traced  branching 
over  small  cells,  filled,  in  the  child,  with  a turbid 
fluid  of  a slightly  red  tinge,  but  in  the  decline  of 
life,  containing  a dusky  yellow  fluid,  These  cells 
do  not  appear  to  communicate  freely  with  each 
other,  since,  by  making  a section  of  the  gland, 
we  only  empty  those  cells  which  have  been  di- 
vided. 

In  the  human  subject,  the  thyroid  gland  is  ge- 
nerally divided  into  two  lobes,  which  are  joined  to 


OF  THE  HEAD  AND  NECK. 


213 


each  other  by  a slip,  which  crosses  the  trachea  a 
few  lines  below  the  cricoid  cartilage.  In  one  in- 
stance, I saw  this  slip  placed  between  the  trachea 
and  oesophagus;  a peculiarity  of  conformation  at 
all  times  to  be  much  dreaded.  Were  this  slip,  so 
situated,  to  become  thickened  and  diseased,  a ter- 
rible dysphagia  and  dyspnoea  would  be  induced; 
affections  which  would  neither  admit  of  alleviation, 
nor  removal  by  art. 

The  thyroid  gland  lies  a little  below  the  cricoid 
cartilage,  its  upper  margin  being  generally  paral- 
lel to  the  second  ring  of  the  trachea.  It  is  co- 
vered anteriorly,  by  the  sterno-hyoideii  muscles, 
yet  not  completely,  for  between  these,  a small 
part  of  the  central  slip  is  exposed.  Laterally, 
the  sterno-thyroideii,  and  omo-hyoideii  muscles, 
lie  over  the  gland,  but  do  not  cover  its  whole 
surface.  The  upper  peak  of  the  lateral  lobe,  where 
it  embraces  the  side  of  the  cricoid  cartilage,  peeps 
from  under  these  muscles. 

The  relations  of  the  different  parts  of  the  gland 
to  the  trachea  and  oesophagus,  must  also  be  stu- 
died, otherwise  the  consequences  resulting  from 
disease  of  these  parts,  cannot  be  satisfactorily  ex- 
plained. These  relations,  however,  will  be  best 
explained,  when  considering  the  diseases  of  the 
thyroid  gland. 

From  the  liberal  supply  of  blood  which  the  thy- 
roid gland  receives,  it  is  liable  to  inflammation, 
which  sometimes  proceeds  to  suppuration.  This 


2,14  ON  THE  SURGICAL  ANATOMY 


state  may  be  either  general  or  partial.  The  ab- 
scess, from  the  effect  of  the  muscles  and  fascia,  is 
flattened  on  its  surface,  it  feels  tense,  and  it  is, 
from  its  mechanical  influence  on  the  subjacent 
parts,  productive  of  considerable  uneasiness.  The 
inconvenience,  however,  is  greater  or  less,  accord- 
ing to  the  part  of  the  gland  which  is  affected.  We 
shall  find,  that  swelling  of  the  right  lobe  is  less  in- 
jurious, than  enlargement  of  either  the  cross  slip 
or  the  left  lobe.  Where  the  disease  is  seated  in 
the  cross  slip,  as  it  lies  directly  over  the  trachea, 
difficulty  in  breathing  forms  the  most  prominent 
feature.  Where  the  left  lobe  is  enlarged,  the  ina- 
bility to  swallow  is  most  complained  of,  but  the 
patient  at  the  same  time,  experiences  difficulty  in 
breathing. 

Although  the  position  of  the  part  of  the  gland 
which  is  affected,  has  considerable  influence  in  mo- 
difying the  effects  produced,  yet  I would  not  wish 
to  be  here  understood,  as  representing  that  it  alone 
is  to  be  taken  into  account.  On  the  contrary,  we 
must  also  view  the  condition  of  the  muscles,  and 
other  parts  covering  the  tumour.  The  former  de- 
termines the  nature  of  the  symptoms,  the  latter  re- 
gulates their  severity.  In  some  diseases,  the  fas- 
cia and  muscles  yield  before  the  swelling.  In 
others  they  resist  its  increase.  In  chronic  affec- 
tions, the  former  takes  place;  in  acute  the  latter. 
In  bronchocele,  dropsy,  and  scrophulous  enlarge- 
ment, the  difficulty  in  breathing  and  swallowing,  is 


OF  THE  HEAD  AND  NECK. 


215 


less  urgent  than  in  inflammation  or  sehirrus.  A 
tumour,  therefore,  of  the  latter  species,  even  of 
small  size,  occasions  a great  degree  of  dysphagia 
or  dyspnoea.  We  search  for  an  explanation  of  the 
difficulty  in  breathing  being  greater  than  the  diffi- 
culty in  swallowing,  in  individual  patients,  and  we 
find  it  accounted  for,  by  the  position  of  the  part  of 
the  gland  affected,  but  we  know  that  all  the  parts 
of  the  gland  are  occasionally  swelled,  where  nei- 
ther the  breathing  nor  swallowing  are  materially 
impaired.  This  depends  on  the  condition  of  the 
fascia  and  muscles. 

When  suppuration  takes  place  in  the  thyroid 
gland,  the  abscess,  from  the  nature  of  its  cover- 
ings, is  long  before  it  bursts.  In  some  instances, 
before  the  integuments  have  given  way,  the  collec- 
tion of  matter  has  been  very  great.  In  one  case 
of  inflammation  of  this  gland,  suppuration  took 
place  in  both  lobes,  pus  continued  to  be  secreted, 
the  abscess  for  a length  of  time  enlarged;  the  in- 
teguments slowly  dilating,  till  they  came  to  form  a 
large  pouch,  which  hung  over  the  sternum,  con- 
taining some  pounds  of  purulent  matter.  At  this 
time  my  brother  saw  the  woman.  The  abscess 
shewed  not  the  least  tendency  to  burst,  but  hectic 
was  considerably  advanced.  On  this  account  he 
advised  that  it  should  be  punctured,  and  the  con- 
tents drawn  off,  in  the  manner  recommended  by 
Mr.  Abernethy,  in  the  treatment  of  psoas  abscess. 
To  this  proposal,  she  most  positively  refused  her 


216 


ON  THE  SURGICAL  ANATOMY 


consent.  For  a fortnight,  therefore,  she  lingered 
on,  each  day  becoming  weaker,  and  each  day  find- 
ing the  difficulty  in  breathing  and  swallowing  in- 
creased. At  last  the  abscess  hurst,  and  fully  dis- 
charged its  contents.  So  soon  as  all  the  matter 
was  evacuated,  she  felt  much  relieved:  her  appe- 
tite improved,  and  the  hectic  decreased.  By  re- 
taining the  sides  of  the  cyst  in  contact,  adhesion 
was  promoted,  and  by  attention  to  diet  and  the  use 
of  medicines,  the  discharge  was  kept  moderate, 
and  ultimately  she  was  cured. 

In  the  case  just  described,  the  matter  burst  out- 
wardly, this,  however,  does  not  uniformly  happen; 
sometimes  the  abscess  opens  into  the  trachea,  and 
at  other  times  it  works  its  way  into  the  oesophagus. 

When  the  thyroid  gland  is  inflamed,  the  means 
usually  employed  for  its  resolution  are  to  be  em- 
ployed. Where  suppuration  takes  place,  from  the 
danger  attending  the  bursting  of  the  abscess  into 
either  the  trachea  or  gullet,  it  is  proper  that  it 
should  be  punctured  so  soon  as  we  have  clearly 
ascertained  that  pus  is  formed.  Where  the  in- 
flammation has  been  simple,  the  wound  heals  rea- 
dily, but  sometimes  the  affection  of  the  gland  is 
connected  with  a peculiarity  of  constitution  which 
retards  the  cure.  In  scrophulous  patients,  after 
the  abscess  has  burst,  or  has  been  opened,  an  in- 
duration and  enlargement  of  the  rest  of  the  gland 
is  apt  to  continue.  This  is  to  be  treated  as  we 
would  other  swellings  of  a similar  nature. 


OF  THE  HEAD  AND  NECK. 


217 


Enlargement  of  the  thyroid  gland,  dependent 
on  chronic  inflammation,  is  not  unfrequently  met 
with  after  parturition.  This  complaint  occurs  as 
often  after  healthy,  as  after  diseased  labours. 
Without  any  obvious  cause,  and  without  much 
pain,  the  gland  slowly  enlarges,  nor  does  the  tu- 
mour, till  large,  occasion  much  uneasiness.  I have 
seen  the  swelling,  after  acquiring  the  size  of  a 
small  orange,  remain  for  several  weeks  stationary, 
and  then  begin  to  decrease,  and  continue  to  dimi- 
nish, till  at  length  the  gland  recovered  its  natural 
size.  It  has  been  known  to  suppurate.  It  re- 
quires no  peculiarity  of  treatment. 

It  has  already  been  mentioned,  that  the  thyroid 
gland  is  naturally  cellular,  and  that  these  cells  are 
filled  with  a fluid,  varying  in  its  colour  at  diffe- 
rent periods  of  life.  Sometimes  this  fluid  accu- 
mulates in  an  individual  cell,  giving  rise  to  dropsy; 
a disease  which  is  to  be  distinguished  by  the  per- 
ception of  fluid,  and  when  the  tumour  is  large  and 
its  coverings  thin,  by  its  transparency,  when  exa- 
mined by  candle-light.  The  diagnosis  is,  how- 
ever, more  difficult,  where  the  fluid  is  tinged  with 
blood,  as  has  occurred  both  to  my  brother  and  to 
myself.  Dr.  Monro,  jun.  also  informs  me,  that  he 
has  found  this  gland  filled  with  blood,  an  affection 
which  Portal  has  likewise  observed.  This  author, 
when  mentioning  the  various  states  of  the  thyroid 
vessels,  adds,  “et  meme  dans  l’interieur  de  cette 
28 


2 IS 


ON  THE  SURGICAL  ANATOMY 


glande  en  trouve  quelque  fois  une  matiere  noiratre, 
corn  me  da  vrai  sang  vieneux  un  pen  coricret.” 

Dropsy  of  the  thyroid  gland  may  be  cured 
either  by  incision,  or  by  puncturing  the  cyst, 
drawing  off  the  fluid,  and  injecting  equal  parts 
of  wine  and  water.  Dr.  Monro,  sen.  mentioned 
in  his  lectures,  that  he  had  seen  a dropsy  in  the 
centre  of  the  gland,  complicated  with  broncho- 
cele  cured  by  a seton,  although  the  glandular 
swelling  still  continued.*  Where  it  is  an  ob- 
ject to  avoid  forming  a cicatrix,  the  fluid  may 
be  sometimes  removed,  by  the  application  of  a 
solution  of  the  muriate  of  ammonia  in  cold 
water. 

Bronchocele  is  another  affection  of  the  thy- 
roid gland,  which  is  frequently  met  with.  It 
is  of  a very  indolent  disposition,  seldom  sup- 
purating, and  often  continuing  for  a great  length 
of  time,  without  producing  so  much  inconve- 
nience as  might  be  expected,  from  the  size  of 
the  tumour.  In  this  complaint,  the  gland  does 
not  appear  to  be  materially  changed  in  its  tex- 
ture. In  its  healthy  state,  numerous  small  cells 
are  found  in  its  substance,  filled  with  fluid.  In 
bronchocele  these  cells  still  exist,  but  they  are 
greatly  enlarged,  and  they  now  contain  a glarv 
fluid,  which,  by  immersion  in  alcohol,  is  readily 
coagulated.  J 

* Manuscript  notes  taken  by  Dr.  Brown. 

t Baillie’s  Morbid  Anatomy,  Appendix,  p.  29,  and  Baillie’s  Plates, 
Fasibulus,  2d,  Table  1st. 


OF  THE  HEAD  AND  NECK. 


219 


Bronchocele  is  met  with  in  every  different 
situation  in  life,  but  it  is  more  frequently  observ- 
ed in  some  countries  than  in  others.  In  Switzer- 
land, many  individuals  are  found,  in  whom  the 
mental  faculties  are  debased  through  every  shade 
to  the  lowest  degree  of  fatuity.  These  crea- 
tures are  called  Cretins.  A considerable  portion 
of  the  Cretins  have  an  enlargement  of  the  thyroid 
gland;  hence  Fodere,*  and  several  other  respect- 
able authors  ascribe  the  affection  of  the  mind  to 
the  state  of  the  thyroid  gland.  For  this,  how- 
ever, there  appears  to  be  no  foundation,  since  the 
mental  faculties  are  from  birth  weak,  and  in 
many  the  fatuity  is  complete,  where  there  is  no 
enlargement  of  the  thyroid  gland,  or  where  the 
tumour  is  not  bigger  than  a walnut;  a size  which 
can  have  no  influence  in  retarding  the  circulation 
to,  or  from  the  brain.  Besides,  we  have  the 
direct  testimony  of  Dr.  Reeve, f that  in  those 
countries  where  Cretins  are  numerous,  many 
people  of  sound  and  vigorous  minds  have  broncho- 
cele. Facts,  therefore,  will  lead  us  to  consider  the 
combination  of  bronchocele  and  cretinism  as 
accidental;  nor  shall  we  have  much  hesitation  in 
admitting  this,  when  we  remember,  that  in  some 
parts  of  this  country,  bronchocele  is  very  fre- 
quent, where  cretinism  is  seldom  if  ever  met  with. 

* Essai  sur  le  Goitre,  et  Cretinisme,  par  M.  Fodere. 

t Dr.  Reeve’s  Paper  on  Cretinism,  Edin.  Med.  and  Surgical  Journal 
vol.  v.  p.  31. 


220  ON  THE  SURGICAL  ANATOMY 


Cretinism  is  supposed  by  Pinel,  who  has  very 
clearly  described  this  disease  in  his  work  on  men- 
tal derangement,  to  arise  from  the  state  of  the 
atmosphere.  This  author  has  observed,  that 
where  cretinism  prevailed,  the  air  was  hot  and 
moist;  an  observation  corroborated  by  Dr.  Reeve, 
who  adds,  that  filthiness,  and  neglect  of  moral 
education,  have  no  small  share  in  debasing  the 
faculties  of  the  mind.  That  these  causes  are  suf- 
ficient to  induce  fatuity  in  its  various  shades,  we 
can  readily  believe,  but  we  know  that  bronchocele 
may  take  place  without  their  operation.  In 
Derbyshire  the  disease  is  endemic. 

Prosser,  who  has  described  this  complaint,  in- 
forms us,  that  the  tumour  generally  begins  be- 
tween the  eighth  and  twelfth  year,  that  it  enlar- 
ges slowly  during  a few  years,  till  at  last  it  aug- 
ments pretty  rapidly  in  size,  and  forms  a bulky 
pendulous  tumour.  The  pain  attendant  on  this 
swelling  is  but  trifling,  and  in  the  incipient  stage 
of  the  complaint,  the  gland  is  compressible  and 
moveable,  but  latterly  it  becomes  solid,  and  ad- 
heres to  the  neighbouring  parts.* 

This  author,  whose  account  of  the  origin,  pro- 
gress, symptoms  and  termination  of  bronchocele, 
it  is  to  be  regretted,  is  neither  full,  clear,  nor 
satisfactory,  tells  us,  that  the  tumour  generally 
induces  permanent  dyspnoea;  .that  by  hurrying 
the  breathing,  the  difficulty  is  augmented,  and 

r Prosser,  page  4. 


OF  THE  HEAD  AND  NECK. 


221 


where  the  swelling  is  very  large,  it  occasions 
wheezing.  According,  however,  to  his  own  tes- 
timony, these  are  not  uniform  occurrences;  some- 
times even  where  the  gland  has  been  much  en- 
larged, the  difficulty  in  breathing  has  been  tri- 
lling. As  he  is  silent  with  respect  to  the  locality 
of  the  tumour,  and  forgets  to  mention  the  state  of 
the  muscles  in  these  cases,  we  can  only,  from  the 
result  of  other  instances,  conjecture,  that  it  was 
occasioned,  either  by  the  position  of  the  swelling, 
or  by  the  condition  of  the  muscles.  Had  these 
circumstances  been  explicitly  mentioned,  we 
would,  I believe,  find  little  difficulty  in  account- 
ing for  the  diversity  of  effect  produced. 

When  the  lateral  lobes  of  the  gland  are  alone 
affected,  a fossa  will  be  formed  in  the  front  of  the 
neck,  during  each  time  that  the  patient  swallows 
a mouthful  of  food.  Some  consider  this  as  the 
most  unequivocal  symptom  of  bronchocele,  but  it 
is  not  a uniform  occurrence.  Indeed,  where  the 
cross  slip  is  equally  enlarged  as  the  lateral  lobes, 
this  hollow  cannot,  and  never  is  distinctly  formed. 
The  resistance  afforded  by  the  tumour,  prevents 
the  elevation  of  the  larynx  from  taking  place  in 
a due  degree,  and  consequently  only  a slight  hol- 
low is  produced. 

Where  one  lateral  lobe  is  alone  enlarged  in 
bronchocele,  where  it  is  dropsical,  or  where  it 
contains  a collection  of  inky  fluid,  the  swelling,  by 
its  extension  towards  the  side  of  the  neck,  is  gen- 


222  ON  THE  SURGICAL  ANATOMY 

erally  placed  in  front  of  the  common  carotid  ar- 
tery; and  from  its  action,  the  tumour,  as  in  en- 
largement of  the  concatenated  glands,  receives  an 
impulse,  it  seems  to  pulsate,  it  resembles  aneu- 
rism, but  may  readily  be  distinguished  from  that 
disease. 

As  a reference  to  individual  cases  is  always  to 
be  preferred  to  general  description,  I shall,  to 
illustrate  some  points  connected  with  disease  of 
the  thyroid  gland,  relate  the  following  case,  which 
I had  an  opportunity  of  examining  a few  years 
ago.  The  person,  a female,  was  far  advanced 
in  life,  and  the  bronchocele  was  pretty  large,  the 
right  lobe  of  the  thyroid  gland  was  as  large  as  a 
a full  sized  orange,  elastic,  soft  in  its  consistence, 
and  uniform  in  its  surface.  In  regard  to  its  posi- 
tion, I may  mention,  that  when  the  head  was  bent 
back,  its  upper  extremity  was  placed  just  three 
finger  breadths  below  the  angle  of  the  jaw,  and 
its  termination  was  only  one  finger  breadth  from 
the  clavicle.  It  measured  from  above  to  below 
five  finger  breadths.  A considerable  portion  of 
the  tumour  lay  anterior  to  the  margin  of  the  ster- 
no-mastoid  muscle;  a part  of  it  was  covered  by 
that  muscle,  and  the  rest  extended  backward 
from  beneath  the  muscle,  into  the  triangular  space 
between  the  sterno- mastoid,  the  trapezius,  and  the 
clavicle.  The  tumour  was  moveable,  the  skin 
covering  it  was  free  from  discoloration,  and  the 
muscles  were  in  no  degree  rigid. 


OF  THE  HEAD  AND  NECK. 


223 


In  the  natural  position  of  the  left  lobe  a round 
knob  was  perceived,  having  apparently  little  con- 
nexion with  the  general  swelling.  Just  over  the 
oesophagus  another  knob,  about  the  size  of  a hazel 
nut,  was  distinctly  felt,  and  by  pressure  could  be 
moved  about.  Beneath  the  sterno- mastoid  mus- 
cle the  enlarged  gland  was  lobulated  and  clustered 
into  small  processes,  precisely  resembling  a chain 
of  enlarged  concatenated  glands.  Indeed,  had  I 
alone  trusted  to  the  impressions  received  before 
dissection,  I would  have  been  led  to  believe  that 
the  lymphatic  glands  of  the  neck  were  actually 
swelled,  and  besides  that  several  of  the  conglobate 
glands  placed  behind  the  sterno-mastoid  muscle, 
between  it  and  the  trapezius,  were  also  affected; 
for  into  that  space  processes  from  the  left  lobe  of 
the  thyroid  gland  extended. 

When  the  integuments  and  the  fibres  of  the  pla- 
tysma  mvoides,  which  were  pale  and  flabby,  were 
removed,  the  cervical  fascia  was  exposed.  It  was 
slightly  thickened,  but  could  hardly  be  said  to  be 
firmer  than  in  its  natural  state.  The  whole  ex- 
tent, however,  of  the  tumour,  was  closely  embrac- 
ed by  a firm,  strong,  and  aponeurotic  capsule, 
which  had  very  little  adhesion  to  the  gland. 

Before  examining  further,  the  arteries  and  veins 
of  the  neck  were  filled  with  wax.  The  following 
are  the  notes  taken  at  the  time  I dissected  the 
body:— 


224 


ON  THE  SURGICAL  ANATOMY 


“On  the  right  side,  the  common  carotid  is  co- 
vered by  the  tumour,  till  it  has  reached  to  the  level 
of  the  upper  margin  of  the  thyroid  cartilage.  At 
this  spot  the  tumour  terminates,  and  here,  from 
the  tracheal  side  of  the  external  carotid,  the  up- 
per thyroid  artery  arises.  It  ascends  along  the 
middle  region  of  the  neck,  till  it  reaches  opposite 
to  the  horn  of  the  os-hyoides,  which  implies  that 
it  is  at  that  part  where  it  is  covered  merely  by 
the  skin,  platysma  myoides,  and  fascia.  Having 
reached  this  point  it  hoops  round  the  upper  thy- 
roid vein,  and  then  makes  a sudden  turn  down 
to  the  thyroid  gland.  It  is  a vessel  nearly  as 
large  as  the  carotid  itself.  The  right  inferior 
thyroid  artery  is  nearly  as  large,  and  it  touches 
the  gland  about  two  finger-breadths  above  the 
clavicle,  at  a part  where  it  is  covered  by  both 
the  sterno-mastoid  and  sterno-thyroid  muscles. 
On  the  left  side  the  arteries  are  not  so  large  as  on 
the  right;  but  they  are,  from  the  greater  flatness 
and  extent  of  the  tumour  on  that  side,  more  com- 
pletely covered.  The  veins  over  the  swelling  are 
dilated  and  very  numerous,  but  neither  the  exter- 
nal nor  internal  jugular  veins  are  much  enlarged. 
On  both  sides  the  nervus  vagus  and  sympathetic 
nerves  were  much  pressed  by  the  tumour,  and  on 
both  sides  the  nerves  were  thickened.  I care- 
fully examined  these  nerves,  and  found  that  the 
medulla  was  not  increased  in  quantity,  it  was  the 
neurilema  alone  which  was  thickened.” 


OF  THE  HEAD  AND  NECK. 


225 


This  is  a case  which  may  afford  some  useful 
points  to  reflect  on:  It  illustrates  facts  which  ought 
to  be  impressed  on  the  mind  of  every  surgeon;  but 
above  all,  on  the  minds  of  those  who  are  especially 
in  the  habit  of  performing  operations.  Have  not 
we  seen,  that  on  the  left  side  of  the  neck  promi- 
nences jutted  out  from  the  thyroid  gland?  Has  it 
not  also  been  mentioned,  that  previous  to  dissec- 
tion, no  one  could  have  suspected  that  these  were 
not  formed  by  swelling  of  the  concatenated  glands? 
Let  these  circumstances  be  remembered,  for  they 
are  important,  and  would  have  much  influence  on 
our  proceedings,  if  called  to  visit  a patient  in  a 
similar  situation.  I believe,  also,  that  it  will  assist 
in  explaining  some  of  the  cases  of  bronchocele, 
said  to  have  been  combined  with  swelling  of  the 
lymphatic  glands. 

Had  a surgeon  been  called  to  examine  the  pre- 
sent patient  before  death,  he  would,  if  he  had 
formed  an  opinion  that  the  knobs  on  the  left  side 
of  the  neck  were  really  enlarged  glandulss  conca- 
tenate, have  resolved,  without  hesitation,  that  no 
operation  could,  with  a prospect  of  success,  have 
been  undertaken.  But  were  he  acquainted  with 
the  nature  of  the  disease,  and  had  he  known  that 
the  apparent  swelling  of  the  lymphatic  glands  was 
truly  a deception,  arising  from  projections  from 
the  surface  of  the  diseased  thyroid  gland;  and  had 
he  been  aware  that  the  whole  extent  of  the  tumour 
lay  inclosed  in  a capsule,  to  which  it  had  little 
29 


226 


ON  THE  SURGICAL  ANATOMY 


adhesion,  he  might,  perhaps,  have  been  inclined  to 
view  the  question  of  operation  in  a different  light. 

It  is  proper  to  know  that  every  tumour  is  ori- 
ginally contained  in  a capsule  of  fascia,  provided 
the  swelling  arise  from  enlargement  of  any  glan- 
dular organ,  and  also  that  the  adhesion  of  the  one 
to  the  other  is,  in  indolent  tumours,  for  a conside- 
rable length  of  time,  slight.  As  the  disease,  how- 
ever, advances,  the  capsule  and  its  contents  be- 
come blended  into  an  unseemly  mass;  they  are 
completely  incorporated,  and  assume  a similar  ap- 
pearance, and  ultimately,  from  the  surface  of  the 
sheath,  projections  shoot  among  the  interstices  of 
the  muscles,  vessels,  and  nerves,  to  which  they 
become  intimately  attached,  rendering  the  ex- 
cision of  the  morbid  parts  next  to  impracticable. 
But,  in  the  present  instance,  no  such  adhesion  had 
taken  place.  Indeed,  the  union  between  the  cap- 
sule and  the  gland  was  so  slight,  that  I found  no 
difficulty  whatever  in  insinuating  my  finger  be- 
tween the  cyst  and  the  gland,  and  detaching  the 
one  from  the  other,  till  I reached  the  thyroid  ar- 
tery, round  which  I could  most  easily  have  passed 
a ligature.  With  the  gentlest  effort  with  the  fin- 
ger I separated  the  tumour  all  round,  and,  in  suc- 
cession, touched  the  four  arteries,  and  brought 
into  view  the  traclrea  and  gullet,  which  were  forc- 
ed so  much  to  the  left  side,  that  the  right  margin 
of  the  former  occupied  what  ought  to  have  been 
the  position  of  the  left  edge,  and  the  oesophagus 


OP  THE  HEAD  AND  NECK. 


227 


was  still  farther  displaced.  When  in  this  way  I 
had  ascertained  the  practicability  of  extirpating 
this  tumour,  I made  an  incision  into  its  substance, 
and  found  that  it  presented  precisely  the  appear- 
ances belonging  to  bronchoeele. 

It  has  been  proved,  from  the  inspection  of  the 
connexions  of  the  enlarged  thyroid  gland  in  this 
body,  that  it  might  with  a possibility  of  advan- 
tage, have  been  removed  by  operation.  Although 
this  would  have  been  practicable  in  this  instance, 
still  in  others,  the  tumour  may  be  so  situated,  and 
may  have  formed  such  adhesions,  as  to  preclude 
any  attempt  at  extirpation.  The  respiration  and 
swallowing  may  be  both  much  impaired,  and  every 
remedy  may  have  been  tried,  and  failed,  either  to 
procure  the  absorption  of  the  tumour,  or  suppura- 
tion. Under  such  circumstances,  is  it  necessary 
to  leave  the  patient  to  die  a miserable  and  linger- 
ing death?  Or  is  there  any  expedient  which 
may  reasonably  be  employed  to  protract  life,  and 
to  render  existence  more  comfortable?  Such  an 
expedient  is  within  our  reach.  The  dissection  of 
this  case,  proves  its  practicability.  There  it  has 
been  mentioned,  that  the  upper  thyroid  artery  was 
greatly  enlarged;  that  it  was  even  nearly  equal  in 
size  to  the  carotid,  and  also  that  it  lay  very  near 
to  the  surface.  Its  coverings  were  few  and  thin; 
the  pulsation  of  the  artery  strong  and  distinct. 
Placed  as  that  vessel  almost  always  is,  no  one 
would  have  experienced  difficulty  in  reaching  it. 


<228 


ON  THE  SURGICAL  ANATOMY 


The  pulsation  itself  would  be  a guide,  which  would 
conduct  us  easily  and  safely  to  the  vessel.  No 
nerve  of  any  importance  would  come  in  the  way; 
no  muscle  would  require  to  be  displaced;  no  depth 
of  substance  to  be  divided;  no  intricate  dissection 
to  be  performed.  A small  incision  would  expose 
the  vessels  on  which  the  tumour,  in  a great  mea- 
sure, depended  for  its  support.  It  would  have 
been  easy  to  carry  a ligature  round  them,  to  inter- 
cept the  flow  of  blood  to  the  gland  above;  and  till 
the  inferior  vessels  enlarged,  the  tumour  would 
have  more  slowly  increased  in  size.  Not  only  so, 
but  it  will  sometimes  be  actually  reduced,  and  life 
protracted. 

A surgeon,  who  would  decline  extirpating  a 
large  bronchocele,  would  have  little  dread  in  tying 
the  superior  thyroid  arteries.  Not  thyroid  arte- 
ries, as  in  health,  small,  indistinct  in  their  pulsa- 
tion, and  requiring,  consequently,  a more  intricate 
dissection  to  expose  them,  but  arteries  too  large  to 
be  missed.  I would  not,  however,  rest  the  ques- 
tion regarding  the  propriety  of  this  procedure  on 
conjecture;  nor  would  I appeal  to  the  healthy  or 
morbid  connexions  of  the  vessels  alone,  to  prove 
that  they  may  be  safely  tied,  when  the  operation 
has  actually  been  performed  on  the  living  subject, 
and  in  so  far  as  concerns  the  tumour,  with  a fa- 
vourable result,  although  we  must  regret  that  the 
patient  died. 

The  operation  to  which  I allude,  was  performed 


I 

ft 


OF  THE  HEAD  AND  NECK.  229 

by  Mr.  Blizzard,*  who  tied  the  arteries  going  to 
an  enlarged  thyroid  gland,  and  in  a week  the  tu- 
mour was  reduced  one  third  in  its  size.  The  liga- 
tures then  sloughed  off;  repeated  bleeding  took 
place  from  the  arteries,  and  by  the  extension  of 
the  hospital  gangrene,  the  carotid  itself  was  laid 
open.  The  patient  died,  yet  this  does  not  mili- 
tate against  the  repetition  of  the  experiment;  the 
same  might  have  happened  from  merely  opening  a 
rein,  and  in  the  confined  air  of  an  unhealthy  hos- 
pital has  actually  happened. 

In  bronchocele,  or  in  any  other  indolent  swel- 
ling of  the  thyroid  gland,  which,  by  its  mechanical 
effect  on  the  trachea  or  gullet,  is  endangering  life; 
it  has  been  shewn,  that  the  morbid  parts  may,  if 
not  large,  or  if  they  have  not  formed  attachments 
to  the  large  vessels  and  nerves,  be  extirpated;  and 
where  too  big  to  admit  of  extirpation,  its  nutrient 
arteries  may  be  tied.  Mr.  Blizzard’s  case  proves 
the  immediate  effect  of  intercepting  the  blood;  it 
shews  that  the  tumour  will  decrease  in  size.  We 
can,  hardly,  however,  expect  that  in  an  organ 
where  the  vessels  anastomose  so  freely,  the  circu- 
lation will  not  be  soon  re-established,  and  the 
swelling  begin  to  enlarge. 

A tumour,  which  before  its  nutrient  arteries 
were  tied,  was  so  large,  that  it  would  have  been 
folly  to  have  attempted  its  excision,  may,  by  de- 
priving it  of  the  circulation  along  the  two  upper 


Manuscript  Notes  taken  by  Dr.  Brou  n. 


230 


ON  THE  SURGICAL  ANATOMY 


thyroid  arteries,  be  so  reduced,  as  to  allow  the 
operation  to  be  performed,  provided  its  connex- 
ions do  not  prohibit  us  from  interfering.  It  is 
not,  therefore,  the  immediate  effect  on  the  disease 
which  we  are  to  look  to  in  tying  the  arteries, 
we  are  to  anticipate  the  command  which  it  may 
ultimately  give  us  over  the  tumour;  and  conse- 
quently, where  the  swelling,  although  very  large, 
has  not  formed  adhesion  to  the  large  cervical  ves- 
sels and  nerves  we  are  to  urge  the  expediency  of 
tying  its  nutrient  arteries,  as  a prelude  to  other 
proceedings.  We  shall  not,  however,  in  broncho- 
cele, have  occasion  often  to  extirpate  the  thyroid 
gland,  neither  shall  we  require  in  many  cases,  to 
tie  the  thyroid  arteries.  Before  we  do  either  the 
one  or  the  other,  we  must  employ  more  lenient 
measures;  and  it  is  to  be  remembered,  that  the 
younger  the  patient,  the  greater  is  the  probability 
of  our  accomplishing  a cure.  Indeed,  where  the 
disease  has  begun  in  very  young  females,  it  often 
spontaneously  disappears,  when  the  menstrual 
secretion  is  established. 

In  the  treatment  of  bronchocele,  repeated  to- 
pical detraction  of  blood  from  the  tumour,  is 
highly  beneficial.  Electricity  also,  has  sometimes 
a marked  effect,  but  there  is  no  remedy  which  I 
would  more  strongly  advise,  than  regular  and 
long  continued  friction  over  the  tumour.  By  per- 
severance in  this  plan,  a bronchocele  treated  in 
London  was  materially  reduced  in  the  course 


OF  THE  HEAD  AND  NECK, 


231 


of  six  weeks.  Its  good  effects  I have  likewise 
witnessed  myself;  and  it  is  a remedy  highly  re- 
commended by  Girard  in  his  “Traite  des  Lou- 
pes.” It  has  also  been  much  used  in  scrophu- 
lous  tumours  by  Mr.  Grosvenor  of  Oxford,  and 
by  Mr.  Russel  of  Edinburgh.”*  Blisters  also,  I 
have  employed,  and  found  useful.  Caustic  is 
also  sometimes  empirically  employed  to  destroy 
the  tumour;  but  is  seldom  used  by  regular  prac- 

* In  employing  friction,  flannel  covered  with  hair  powder  ought,  to  be 
used,  and  the  parts  ought  to  be  carefully  rubbed  at  least  three  times  a day, 
and  never  for  a shorter  period  than  twenty  minutes  each  time.  By  perse- 
verance in  this  treatment,  it  is  sometimes  astonishing  how  much  effect  is 
produced  on  even  the  most  obstinate  swellings.  A gentleman  some  years 
ago,  was  cured  by  repeated  blisters  and  friction,  of  a large  cluster  of  tu- 
mours in  the  neck,  which  had  resisted  every  other  treatment,  and  where 
blisters  by  themselves,  had  produced  no  diminution  in  their  size.  The 
glandular  swellings  in  this  case,  originated  from  a rawmess  of  the  tonsils 
and  fauces.  This  was  not  dependent  on  any  specific  disease.  Many'  local 
remedies,  were,  without  advantage,  applied  to  the  throat,  and  the  neck 
was  frequently  blistered;  still  the  complaint  gained  ground;  the  debility 
increased,  and  the  patient  was  at  length  informed,  that  he  had  but  a short 
time  to  live.  While  in  this  situation,  an  empiric  was  recommended  to 
him,  as  very  successful  in  the  treatment  of  similar  cases.  By  his  advice, 
he  was  removed  to  the  country.  A large  blister  was  applied  over  the 
enlarged  glands,  and  so  soon  as  it  rose,  the  practitioner  cut  away  the  sepa- 
rated cuticle,  and  briskly  rubbed  the  inflamed  surface  with  coarse  tow. 
Then  he  allowed  the  sore  to  heal;  when  this  was  accomplished,  another 
blister  was  applied,  and  treated  in  a similar  manner.  This  rude  treatment, 
to  which  he  occasionally  added  the  use  of  purgatives,  was  persevered  in 
during  a length  of  time.  Under  it  the  tumours  slowly  decreased;  the  ex- 
coriation of  the  tonsils  and  fauces  lessened,  and  after  a few  months,  all 
trace  of  disease  was  removed. 

About  six  years  afterwards,  the  gentleman  died  of  a complaint,  altoge- 
ther unconnected  with  the  primary  disease. 

This  case  promised  but  little;  the  patient  when  he  put  himself  under 
the  care  of  the  empiric,  had  almost  no  hope  of  recovery;  the  disease  was 
gaining  ground,  and  every  remedy  which  reflection  could  devise,  had  in 
vain  been  tried.  Even  the  very  medicines  which  ultimately  effected  a cure. 


232 


ON  THE  SURGICAL  ANATOMY 


titioners,  although  recommended  by  Celsus  * It 
is  said  to  have  succeeded  where  every  thing  else 
has  failed.  Mr.  T.  Blizzard,  I am  informed,  re- 
commends the  application  of  a gum  plaster,  which, 
from  its  efficacy  in  other  indolent  tumours,  I can 
readily  believe,  may  be  advantageous  in  broncho- 
cele.  I have  also  seen  good  effects  from  friction, 
with  an  ointment  composed  of  one  ounce  ung. 
hyd.  to  one  drachm  camphor. 

In  Switzerland,  great  reliance  is  placed  on  the 
use  of  burnt  sponge  in  the  cure  of  bronchoeele, 
and  various  formulae  are  in  repute.  I have  seen 
it  employed,  but  cannot  say  that  I ever  observed 
any  effect  from  it,  even  where  conjoined  with  mer- 
curial preparations.  I would  give  nearly  the 
same  opinion,  of  all  internal  remedies  which  are 
used  as  specifics  in  this  disease.  I would  place 
my  dependence  on  local  applications,  and  such 
remedies  as  tend  to  keep  the  action  of  the  sto- 
mach and  bowels  regular.  In  two  cases  of  bron- 
chocele  related  by  Dr.  Clarke,  the  patients  were 
cured  by  “the  steady  use  of  the  compound  plas- 
ter of  ammoniac  and  mercury,  conjoined  with  the 
internal  exhibition  of  the  burnt  sponge,  and  occa- 
sional purgatives. "f 

had  been  employed,  but  from  not  being  duly  persisted  in,  nor  sufficiently 
far  pushed,  they  had  failed.  This  affords  a useful  lesson;  it  holds  up  to  our 
view,  that  temporizing  treatment  will  not  succeed  in  obsliuate  cases;  there 
the  most  vigorous,  and  what  mistaken  humanity  would  term  harsh  mea- 
sures, must  be  adopted.  Such  alone  will  overcome  the  morbid  action. 

* Celsus,  lib.  vii.  cap.  13. 

t Edinburgh  Surgical  Journal,  vol.  iv.  p.  280. 


OF  THE  HEAD  AND  NECK. 


233 


Carcinoma,  and  fungus  hacmatodes,  are  also  af- 
fections to  which  the  thyroid  gland  is  subject.  In 
carcinoma,  the  gland  without  any  obvious  cause, 
but  sometimes  after  a blow  in  the  neck,  begins  to 
enlarge.  The  tumour  increases  slowly  in  size,  is 
irregular  on  its  surface,  and  of  a stony  hardness, 
and  from  the  first  the  pain  is  acute  and  lancinat- 
ing, extending  chiefly  upward  along  the  neck. 
The  breathing  and  swallowing  are  greatly  affect- 
ed; the  one,  however,  generally  more  than  the 
other,  according  to  the  part  of  the  gland  which  is 
diseased.  The  muscles  are  rigid;  they  are  firmly 
fixed  to  the  tumour,  and  in  the  latter  stage,  the  in- 
teguments are  matted  and  puckered,  which  never 
happens  in  even  the  largest  bronchocele.  A sa- 
nies fluid  sometimes  collects  in  cysts,  near  to  the 
surface;  these  enlarge  and  force  back  the  mass  of 
the  tumour  against  the  parts  behind;  the  patient 
suffers  the  greatest  distress,  for  he  can  hardly 
breathe,  and  as  to  swallowing  any  thing  but  flu- 
ids, it  is  out  of  his  power.  When  seemingly  about 
to  die,  the  most  prominent  of  the  sacs  gives  way,  a 
small  discharge  of  bloody  ichorous  matter  relieves 
for  a short  time,  but  the  symptoms  soon  recur,  and 
are  relieved  by  the  successive  bursting  of  the 
cysts,  till  at  length  even  that  ceases  to  relieve. 

Widow  M‘Leod,  a poor  woman  above  sixty 
years  of  age,  ascribed  the  beginning  of  a tumour 
of  the  thyroid  gland,  “to  a stress,”  to  use  her  own 
expression,  “of  the  neck,”  which  had  taken  place 
30 


334 


ON  THE  SURGICAL  ANATOMY 


nearly  thirty  years  before.  During  all  that  time, 
she  carried  a tumour  about  with  her,  not  produc- 
tive of  very  great  uneasiness,  yet  still  disturbing 
her.  Latterly,  the  swelling  increased  very  ra- 
pidly, and  without  any  apparent  cause,  enlarged 
to  such  a size,  as  besides  producing  a great  de- 
gree of  deformity,  to  endanger  her  life.  The  state 
of  the  tumour  at  that  time,  I do  not  very  fully 
know,  but  her  surgeons  were  much  astonished, 
when  she  told  them  shortly  afterwards,  that  the 
swelling  was  gone;  they  inquired  how  that  had 
taken  place,  and  were  informed,  that  it  had  been 
occasioned  by  the  bursting  of  the  skin,  and  sub- 
sequent discharge  of  a small  quantity  of  bloody 
serum. 

They,  like  the  patient,  flattered  themselves  that 
the  cure  would  soon  be  complete.  At  the  dis- 
tance of  six  months  after  that  occurrence,  the  wo- 
man came  to  shew  me  the  tumour,  which  had  re- 
turned, and  was  now  worse  than  ever.  For  two 
nights  before  I saw  her  she  had  been  unable  to  lie 
in  the  recumbent  position,  or  even  to  procure  sleep 
in  any  posture.  She  was  in  constant  uneasiness, 
tormented  with  a tension  and  confusion  in  her 
head,  and  worn  out  with  apprehension  of  suffoca- 
tion. She  neither  knew  to  whom  to  apply  for  re- 
lief, nor  what  to  do  to  procure  a momentary  re- 
spite from  suffering.  She  could  not  fetch  her 
breath  without  dreadful  gasping,  neither  could  she 
swallow  till  after  tedious  mastication,  and  even 


OF  THE  HEAD  AND  NECK. 


235 


then  the  morsel  was  thrust  over  with  fear  and 
trembling,  for  she  verily  believed  that  some  time 
or  other  it  would  choke  her. 

The  expression  of  her  suffused  purple  counte- 
nance was  characteristic  of  keen  anxiety  about  her 
fate;  she  dreaded  the  struggles  for  breath  which 
she  soon  felt  she  would  be  obliged  to  make,  if 
something  was  not  done  to  remove  the  tumour. 
No  one  could,  however,  hold  out  any  prospect  of 
this  kind,  nor  afford  her  more  consolation  than  a 
promise,  that  in  the  eventful  period  to  which  her 
disease  was  drawing,  every  thing  would  be  done 
which  it  was  possible  to  accomplish  to  relieve  her. 

When  I saw  her  the  tumour  jutted  out,  as  big  as 
the  fist  on  the  left  side,  and  it  felt  as  hard  as  a 
stone.  On  the  front  of  the  neck  there  was  an  ugly 
puckered  sinus,  just  over  the  cross  slip  of  the  thy- 
roid gland,  from  which  a bloody  ichor  was  dis- 
charged, and  she  always  felt  easiest  when  this  dis- 
charge was  most  profuse.  The  tumour  on  the 
right  side  was  as  large,  but  more  flattened  than  on 
the  opposite,  and  on  the  outer  edge  of  it  the  ca- 
rotid artery  was  felt,  quite  superficial,  labouring 
with  rapid  motion,  and  hard  and  firm  as  a cord. 
It  formed,  when  dilated,  a rope  about  the  size  of 
the  little  finger.  On  the  opposite  side  the  artery 
was  also  pushed  outward,  although  not  to  the  same 
extent.  It  felt  deeper,  and  was  more  restrained 
in  its  action.  The  tumour  was  productive  of 
dreadful  irritation  about  the  larynx,  inducing 


236 


ON  THE  SURGICAL  ANATOMY 


severe  and  reiterated  fits  of  coughing,  during 
which  she  said  “her  head  seemed  ready  to  burst,” 
and  the  eyes  to  start  from  their  sockets. 

Various  medic  nes  were  tried,  but  the  only  re- 
lief she  obtained,  was  from  large  doses  of  the  am- 
moniated  tincture  of  opium. 

She  continued  during  some  months  gradually 
becoming  worse,  and  at  length  died  in  dreadful 
agony. 

On  inspecting  the  body,  the  thyroid  gland  was 
found  to  be  much  enlarged.  On  the  right  side 
there  were  several  pretty  large  cysts  attached  to 
the  gland,  filled  with  bloody  serum,  and  studded 
over  on  their  inner  surfaces  with  little  cartilagin- 
ous knobs.  On  this  side,  the  internal  jugular  vein, 
from  a little  below  the  angle  of  the  jaw  down  to 
near  the  chest,  was  completely  obliterated.  The 
blood  was  sent  across  to  the  opposite  vein  by  a 
large  communicating  vessel  which  ran  parallel  to 
the  body  of  the  hyoid  bone.  The  substance  of  the 
sympathetic  and  eighth  pair  of  nerves  was  thick- 
ened and  indurated,  and  the  trachea  and  larynx 
were  flattened  by  the  pressure  of  the  tumour. 
The  substance  of  the  tumour  itself  was  distinctly 
carcinomatous.  The  membranous  intersections, 
and  the  softer  texture  of  this  disease,  were  too 
characteristic  of  its  nature  to  be  mistaken. 

From  tiie  description  of  the  spongoid  tumour 
given  by  my  brother,*  and  of  the  fungus  liaema- 


* Dissertations  on  Inflammation,  by  John  Burns,  vol.  2. 


OF  THE  HEAD  AND  NECK. 


237 


todes  by  Mr.  Hey,*  we  learn  that  the  disease  be- 
gins with  a small  colourless  swelling,  elastic  when 
touched,  firmer  the  deeper  it  is  seated,  and  which, 
if  covered  by  a fascia,  is  very  tense.  As  the  tu- 
mour increases,  it  acquires  more  and  more  of  its 
characteristic  trait,  it  becomes  more  elastic  than 
formerly,  generally  projects  more  at  some  points 
than  at  others,  and  seems  to  contain  within  it  a 
quantity  of  fluid.  This  is,  however,  a deception; 
from  a puncture,  only  a very  small  portion  of 
bloody  ichor  issues,  a quantity  so  immaterial  as 
not  to  lessen  the  size  of  the  swelling. 

The  prominent  points  are  the  most  elastic,  are 
covered  with  the  most  diseased  integuments,  and 
are  generally  marked  with  small  varicose  veins, 
from  which  they  derive  a bluish  livid  colour.  Be- 
neath these  diseased  integuments  the  rudiments  of 
fungi  are  placed;  this  being  a complaint  in  which 
there  is  a disposition  to  form  fungus,  previous  to 
the  bursting  of  the  skin.  The  fungi  are  darker 
coloured  than  the  rest  of  the  tumour,  which  con- 
sists of  a light  grayish,  medullary  looking  sub- 
stance, disposed  in  irregular  cells,  which  are  form- 
ed by  laminae,  arising  either  from  the  bursae  of  the 
joints,  from  a fascia  in  the  neighbourhood,  or  from 
the  periosteum  of  the  bones  themselves.  Where 
the  tumour  has  existed  for  a length  of  time,  the 
parts  in  the  vicinity  come  to  suffer.  The  bones 
are  softened,  their  cancelli  are  removed,  and  their 


* Observations  in  Surgery,  by  Mr.  Uey. 


238 


ON  THE  SURGICAL  ANATOMY 


place  supplied  by  a soft  mass  of  cineritous  looking 
matter;  the  muscles  are  entirely  changed,  they 
lose  completely  their  fibrous  texture,  hut  they  still 
retain  their  shape.  They  are  either  of  a dusky 
white  or  brown  colour. 

When  the  integuments  over  a protuberance 
burst,  a small  quantity  of  bloody  ichor  is  discharg- 
ed, a fungus  rapidly  sprouts  from  the  orifice,  over 
the  margin  of  which  it  is  soon  folded.  From  the 
surface  of  this  fungus  a profuse  haemorrhage  fre- 
quently takes  place,  and  at  all  times  it  is  smeared 
over  with  a film  of  bloody  lymph. 

About  this  time  the  patient  begins  to  suffer  from 
hectic;  formerly  his  nights  had  been  restless,  ow- 
ing to  the  acuteness  of  the  pain;  now  he  is  pre- 
vented from  sleeping  by  the  febrile  exacerbations, 
equally  as  by  the  local  pain;  and  now  the  lym- 
phatic glands  begin  to  swell.  They  assume  the 
same  morbid  condition,  but  the  secondary  affec- 
tion is  more  rapid  in  its  progress  than  the  pri- 
mary. 

I have  thus  detailed  the  general  appearances 
presented  by  fungus  hsematodes,  a disease,  which, 
although  fully  established  to  be  altogether  differ- 
ent from  cancer,  is  yet,  perhaps,  not  perfectly  un- 
derstood. There  are  several  of  its  features  with 
which  we  are  by  no  means  familiar;  we  are  ac- 
quainted with  its  more  common  character,  but 
many  of  its  modifications,  I am  fully  persuaded, 
remain  to  be  demonstrated.  Mr.  Wardrop,  in  his 


OF  THE  HEAD  AND  NECK. 


239 


late  work  on  Fungus  Haematodes,  has  very  accu- 
rately pointed  out  the  differences  in  texture  in  car- 
cinoma and  this  disease;  he  has  shewn  them  to  be 
very  dissimilar.  This  is  one  step  gained,  but 
there  still  remain  important  matters  for  investiga- 
tion; we  have  yet  to  learn  wherein  cancer  and 
fungus  haematodes  differ  in  their  external  appear- 
ances; we  have  also  to  ascertain  whether  these 
two  diseases  can.  or  ever  do  exist  at  the  same  time 
in  different  parts  of  the  same  body,  or  in  different 
parts  of  the  same  organ;  we  have  also  to  inquire 
whether  fungus  haematodes,  and  medullary  sar- 
comae  be  identically  the  same  diseases,  or  whether 
they  are  really  dissimilar  in  their  nature. 

These  are  points  of  considerable  consequence, 
and  were  we  able  to  solve  them,  it  would  mate- 
rially improve  our  knowledge,  not  only  of  these 
complaints,  but  it  would  also  elucidate  the  doc- 
trine of  tumours  in  general.  Unfortunately,  how- 
ever, we  are  hardly  possessed  of  a sufficient  num- 
ber of  facts,  to  decide  on  any  of  these  questions. 
What  little  information  we  have  obtained  from  the 
inspection  of  these  diseases  in  the  living  body,  and 
from  the  examination  of  the  morbid  parts  after 
death,  I shall  shortly  detail.  I cannot,  however, 
do  this,  without  making  an  apology  for  their  in- 
sufficiency; indeed,  they  are  more  to  be  consider- 
ed as  hints  to  future  observers,  than  as  affording 
any  very  defined  idea  of  the  subjects  in  question. 


240 


ON  THE  SURGICAL  ANATOMY 


In  carcinoma,  the  tumour  is  solid,  irregular  on 
its  surface,  and  incompressible;  whereas,  in  fungus 
hsematodes,  the  tumour  is  yielding,  it  is  elastic  un- 
der the  finger;  it  is  indeed  irregular  on  its  surface, 
but  so  far  from  the  prominent  points  being  the 
most  stony  as  in  carcinoma,  they  are  really  the 
most  compressible.  They  even  communicate  an 
obscure  feeling  of  fluid.  In  carcinoma,  after  the 
skin  has  given  way,  the  margins  of  the  ulcer  are 
thin,  livid,  glassy,  and  often  retroflected;  but  in 
fungus  hsematodes,  I have  never  seen  a case  in 
which  the  edges  of  the  sore,  were  in  even  the 
slightest  degree  reflected.  Generally,  in  the  lat- 
ter disease,  the  fungus,  in  the  course  of  a few'  days, 
is  spread  over  the  margin  rf  the  opening,  through 
which  it  has  passed,  and  I have  repeatedly  seen 
the  neck  of  the  fungus  so  closely  embraced  by  the 
skin,  that  a profuse  venous  haemorrhage  wTas  pro- 
duced from  the  surface  of  the  cauliflower-like  ex- 
crescence. In  carcinoma,  a fungus  does  also  some- 
times spout  out  from  the  ulcers,  but  from  the 
sloughing  of  this,  and  of  the  mass  of  the  tumour,  a 
deep  cavern  is  formed,  bounded  by  livid,  under- 
mined, and  ragged,  and  occasionally  reverted 
edges.  In  fungus  hsematodes,  I never  knew  a loss 
of  substance,  except  where  the  neck  of  the  fungus 
was  tightly  begirt  by  the  skin;  then,  indeed,  the 
fungus  has  dropped  off  in  the  same  way  that  a po- 
lypus decays,  when  a ligature  is  fixed  round  its 
root.  Carcinoma  and  fungus  hsematodes  resemble 


OF  THE  HEAD  AND  NECK. 


241 


each  other  in  some  features;  in  both,  there  is  a to- 
tal destruction  of  the  natural  texture  of  the  part 
affected;  in  both,  there  is  a disposition  to  form 
fungus,  but  still,  the  appearance  of  the  fungus  is 
different  in  the  two  diseases.  “The  fungus,  instead 
of  having  a firm  texture,  like  that  which  sometimes 
arises  from  the  cancerous  ulcer,  is  a dark  red  or 
purple  mass,  of  an  irregular  shape,  and  of  a soft 
texture,  is  easily  torn,  and  bleeds  profusely  when 
slightly  injured.’’*  In  carcinoma,  the  fungus 
sometimes  sloughs  from  some  increased  action  in 
the  diseased  parts,  but  in  fungus  hsematodes,  the 
fungus  progressively  enlarges,  and  only  sloughs 
from  accidental  causes. 

In  their  external  characters,  therefore,  we  per- 
ceive a marked  difference  between  carcinoma  and 
fungus  hsematodes.  The  internal  differences  are 
not  less  striking.  “The  morbid  growth  in  fungus 
hsematodes,  consists  of  a soft  pulpy  matter,  which 
mixes  readily  with  water,  and  is  hardened  by 
acids,  and  boiling  in  water.  It  has  been  also 
compared  by  all  who  have  attempted  to  describe 
it,  to  medullary  matter  in  colour  and  consistence.”* 
“The  colour  of  the  tumour  when  small  is  generally 
of  a pale  grey,  or  brownish  red  hue;  but  when  it 
is  large,  the  different  portions  which  are  separa- 
ted from  one  another  by  capsules,  assume  very 
different  appearances,  the  general  mass  being  thus 
composed  of  a number  of  parts  differing  in  colour 

* Wardrop,  page  ISO. 


31 


M2 


ON  THE  SURGICAL  ANATOMY 


and  structure.  Some  of  these  are  of  the  colour 
and  consistence  of  brain,  some  are  of  a deep  yel- 
low colour,  and  some  of  them  have  the  colour  and 
consistence  of  the  boiled  yolk  of  an  egg:  some 
portions  are  of  a dark  red  colour,  like  masses  of 
coagulated  blood,  and  others  more  resemble 
liver. Sometimes  portions  of  it  are  excavated, 
the  little  cells  containing  a bloody  fluid,  and  al- 
ways the  tumour  is  intersected  by  thin  membra- 
nous septa,  which  separate  the  different  lobes  of 
which  it  is  composed  from  each  other.  Some- 
times several  of  these  lobes  are  hard  and  car- 
tilaginous, and  in  other  instances  they  are  ossified. 

“The  scirrhous  tumour,  from  its  commence- 
ment, is  a hard,  firm,  and  incompressible  mass, 
which,  by  a minute  examination,  will  be  found  to 
be  composed  of  two  distinct  and  very  different 
substances.  The  one  is  hard  and  fibrous,  the 
other  more  soft,  and  apparently  inorganic. 

“The  fibrous  substance  composes  the  chief  part 
of  the  scirrhous  mass,  and  consists  of  septae,  which 
are  opaque,  and  commonly  of  a paler  colour,  than 
the  soft  part.  These  septae  are  very  unequal  in 
their  length,  breadth,  and  thickness,  and  disposed 
in  various  directions,  so  as  to  form  sometimes  a 
solid  mass,  and  at  other  times,  a greater  or  lesser 
number  of  irregular  cavities,  which  contain  the 
soft  part. 

“The  soft  or  inorganic  part  is  sometimes  semi- 
transparent, of  a bluish  colour,  and  resembling  in 

* Wardrop,  page  106, 


OF  THE  HEAD  AND  NECK. 


243 


consistence,  softened  glue.  In  other  cases,  it  is 
softer,  somewhat  oleaginous,  and  more  resembling 
cream  in  colour  and  consistence. 

“The  proportion  and  mode  of  distribution  of 
these  two  substances  are  very  different  in  scirrhous 
affections  of  the  same,  and  of  different  organs;  and 
give  that  great  variety  which  may  be  observed  by 
examining  a number  of  tumours  of  this  kind.  In 
some,  the  fibrous  part  is  most  conspicuous,  and  is 
condensed  into  a very  solid  form,  having  the  ap- 
pearance of  a nucleus,  from  which  septse  come  off 
in  all  directions,  and  giving  a section  of  the  tu- 
mour a radiated  appearance.  This  is,  perhaps, 
the  most  usual  form  of  the  disease:  in  some,  the 
tumour  is  very  irregularly  shaped,  and  nearly  a 
uniform  hard  mass,  in  which  scarcely  any  defined 
structure  can  be  traced.  In  some,  the  fibrous 
part  has  a cellular  appearance,  the  cells  being 
filled  with  the  soft  pulpy  matter,  which  can  be 
readily  pressed  out  with  the  finger.  In  others,  it 
has  cysts  formed  in  it  of  various  dimensions,  which 
generally  contain  a bloody  or  dark  chocolate- 
coloured  fluid,  and  have  sometimes  a fungus  tu- 
mour growing  within  them.  It  occasionally  hap- 
pens, too,  that  parts  of  scirrhous  tumours  acquire 
a great  degree  of  hardness,  being  converted  into  a 
substance  resembling  cartilage,  in  which  bony  de- 
positions are  sometimes  formed. 

When  scirrhous  tumours  are  formed  in  the 
substance  of  a gland,  their  limits  cannot  be 


244  ON  THE  SURGICAL  ANATOMY 


accurately  determined,  the  two  structures  being 
apparently  inseparably  connected.  At  other 
times,  they  condense  the  cellular  membrane, 
which  is  in  their  immediate  vicinity,  and  acquire 
a more  circumscribed  appearance 

I have  thus,  from  my  own  observation,  and  that 
of  others  corroborated  by  my  own,  endeavoured 
to  draw  the  distinction  between  the  external  and 
internal  characters  of  carcinoma  and  fungus  hae- 
matodes.  It  has  appeared  that  the  features  in 
these  diseases  are  distinct  and  well  defined.  If, 
therefore,  we  meet  with  one  part  of  a tumour  pre- 
senting the  decided  marks  of  carcinoma,  and  ano- 
ther part  indelibly  impressed  with  the  lineaments 
of  fungus  haematodes,  we  must  surely  conclude, 
that  both  these  diseases  have  coexisted  in  the 
same  body.  This  remark  I have  been  led  to 
make,  from  the  result  of  careful  dissection  which 
I made  of  a diseased  breast,  latelv  extirpated  by 
Dr  Brown.  One  extremity  of  this  organ  pre- 
sented the  decided  features  of  fungus  haematodes, 
while  the  other  end  displayed  the  peculiar  and 
characteristic  texture  of  carcinoma.  A single 
case,  it  may  be  said,  is  not  sufficient  to  establish 
so  important  a fact;  yet,  although  I cannot  speak 
positively  as  to  any  other  instance  of  a similar 
combination,  I am  pretty  certain  that  such  have 
come  under  my  observation.  Neither  is  it  incon- 
sistent with  established  facts,  to  suppose  that  one 


Wardrop,  page  181,  et  seq. 


OF  THE  HEAD  AND  NECK. 


245 


part  of  the  tumour  may  be  of  one  specific  nature, 
and  another  of  a different.  From  what  I my- 
self have  witnessed,  I believe  that  one  part  of  a 
tumour  may  be  scrophulous,  while  another  may 
be  of  the  nature  of  fungus  hsematodes. 

It  seems  that  fungus  hsematodes  has  now  be- 
come a genera]  name  for  all  non  descript  tumours, 
as  heretofore  scirrhous  was.  Many  dissimilar 
affections  are  thus  huddled  together.  No  two 
surgeons  have  the  same  ideas  regarding  the 
morbid  texture  of  this  disease;  therefore,  what- 
ever does  not  resemble  any  of  the  complaints 
with  which  they  were  already  familiar,  must  be 
fungus  hsematodes.  My  brother  and  Mr.  Hey 
gave  an  account  of  the  general  appearances  pre- 
sented by  this  affection.  Mr.  Abernethy  next 
published  an  account  of  a disease  which  he  called 
medullary  sarcoma.  Surgeons  immediately  in- 
ferred, because  some  features  were  common  to 
fungus  hsematodes  and  medullary  sarcoma,  that 
they  must  be  identically  the  same  disease.  That 
they  are  not,  however,  is  pretty  certain,  from  the 
nature  of  the  morbid  parts  themselves. 

In  fungus  hsematodes  the  body  of  the  tumour 
is  intersected  by  numerous  membranous  bands, 
but  in  medullary  sarcoma  the  mass  is  of  uniform 
pulpy  consistence,  and  resembles  in  colour  the 
cortical  portion  of  the  brain.  In  the  former,  we 
can  wash  out  the  soft  brain- looking  matter,  while 
the  membranous  bands  arc  left  remaining;  if  we 


246 


ON  THE  SURGICAL  ANATOMY 


treat  a section  of  the  latter  tumour  in  a similar 
manner  we  leave  only  the  capsule  in  which  it 
was  contained,  and  a number  of  floculi  hanging 
from  its  inner  surface.  I have  seen  and  examined 
several  specimens  of  medullary  sarcoma,  and 
uniformly  with  the  same  result;  but  the  best  ex- 
ample of  it  I ever  saw  was  from  the  ovarium  of 
a lady  about  forty.  The  tumour  was  very  large, 
its  centre  contained  a considerable  quantity  of 
glary  fluid,  and  the  surface  of  the  cyst  which 
contained  this  was  studded  over  with  numerous 
projections,  each  about  the  size  of  an  orange. 
When  these  were  cut  into  I found  them  composed 
of  a pulpy  organized  mass  of  a medullary  con- 
sistence, and  of  various  shades  in  different  places. 
Some  parts  of  the  tumour  were  of  a dark  purple 
tinge,  and  others  were  of  a dirty  yellow  hue. 
The  line  of  junction  of  the  dark  coloured  with  the 
brighter  substance  was  abrupt  and  well  defined. 

Mr.  Abernethy,  when  treating  of  medullary 
sarcoma,  informs  us,  that  “the  tumour,  in  those 
cases  of  the  disease  which  I have  most  frequently 
met  with,  has  been  of  a whitish  colour,  resem- 
bling, on  a general  and  distinct  inspection,  the 
appearance  of  the  brain.  The  disease  is  usually 
of  a pulpy  consistence,  and  I have,  therefore, 
been  induced  to  distinguish  it  by  the  name  of 
medullary  sarcoma.  Although  I have  more  fre. 
quently  met  with  this  disease  of  a whitish  colour, 
yet  I have  often  seen  it  of  a brownish  red  ap- 


OF  THE  HEAD  AND  NECK. 


247 


pearance.  Which  is  the  most  common  I cannot 
decide,  the  structure  and  feel  of  both  are  the 
same,  and  their  progress  is  also  similar,  they  are, 
therefore,  to  be  considered  as  varieties  of  one 
species.”*  That  the  membranous  septse  which 
are  never  wanting  in  fungus  hsematodes,  were 
not  existing  in  the  disease  described  by  Mr. 
Abernethy,  was  accidentally  demonstrated  in  one 
of  Mr,  Abernethy’s  dissections.  “I  took  out  the 
lumbar  glands  and  put  them  in  water;  and  the 
weather  being  extremely  hot  when  I examined 
them  next  day,  I found  that  all  the  unorganized 
deposited  matter  which  had  enlarged  them  had 
become  putrid,  and  was  washed  away,  leaving  the 
capsule  of  the  gland,  and  a congeries  of  fiaculent 
fibres,  occupying  the  interior  of  it.”f 

That  the  structure  of  medullary  sarcoma  is 
different  from  that  of  fungus  hsematodes,  is,  I 
think,  demonstrated;  we  have,  however,  to  regret, 
that  they  are  equally  intractable  in  their  disposi- 
tion, and  equally  fatal  in  their  issue. 

Medullary  sarcoma  is  sometimes  met  with  in 
the  thyroid  gland.  It  begins  with  an  elastic 
swelling,  at  first  uniform  to  the  touch,  but  by 
degrees,  becoming  unequal  on  its  surface;  the 
muscles  are  rigid,  the  integuments  are  tense,  and 
in  the  advanced  stage  they  are  dark  coloured; 
and  over  the  prominent  parts  are  bestudded  with 


Abernethy’s  Observations  on  Tumours,  page  51.  t Ibid,  p.  5G 


248 


ON  THE  SURGICAL  ANATOMY 


varicose  veins,  which  I have  noticed  where  the 
tumour  was  not  larger  than  a billiard  ball.  At 
the  same  time  the  looks  were  squalid,  the  nights 
restless,  the  respiration  difficult  and  wheezing, 
deglutition  much  impeded,  the  pulse  frequent, 
the  pain  of  the  tumour  great,  lancinating,  and 
almost  incessant,  although  liable  to  exacerba- 
tions. The  patient  generally  dies  before  the  tu- 
mour has  become  very  large,  but  to  this  there 
are  occasional  exceptions.  I have  once  seen  the 
tumour  occupying  the  left  side  of  the  neck,  com- 
mencing a little  to  the  right  side  of  the  junction 
of  the  alse  of  the  thyroid  cartilage,  projecting 
outward  beyond  the  transverse  processes  of  the 
cervical  vertebrae,  descending  till  it  came  in  con- 
tact with  the  clavicle,  and  stretching  upward  till 
it  touched  the  margin  of  the  lower  jaw  bone. 

The  patient  was  a most  miserable  creature, 
unable  to  breathe  or  swallow,  except  with  great 
difficulty,  and  with  many  struggles.  Her  sur- 
geons visited  her,  they  saw  her  deplorable  con- 
dition, they  advised  one  thing  after  another,  and 
each  did  as  little  good  as  the  one  which  had  gone 
before: — They  allowed  the  swelling  to  increase 
to  the  enormous  size  I have  mentioned,  and  then, 
to  give  momentary  respite,  they  made  a long  and 
deep  gash  into  the  tumour.  They  practised  an 
old  and  pernicious  expedient,  which  cannot  be  too 
strongly  reprobated.  It  was  an  operation  for 
which  there  could  be  no  apology.  The  tumour 


OF  THE  HEAD  AND  NECK. 


249 


was  evidently  of  a specific  nature,  and  the  sur- 
geon ought  to  have  known,  that  to  cut  into  such  a 
mass,  and  not  at  the  same  time  to  remove  it  en- 
tirely, was  a certain  way  to  exasperate  the  dis- 
ease, and  to  destroy  the  patient. 

I must  not  quit  the  history  of  this  case 
until  I have  explained  some  other  points  con- 
nected with  it.  I must  advert  to  the  position 
of  the  common  carotid  artery,  which  was  deep- 
ly buried  amidst  the  diseased  substance.  It 
lay  imbedded  in  the  very  centre  of  the  tu- 
mour, and  in  making  the  extensive  wound 
into  the  swelling,  the  knife  had  penetrated  to 
within  the  hundredth  part  of  an  inch  of  the 
coats  of  the  vessel;  how  it  escaped  injury  is 
hardly  conceivable:  it  was  not  from  the  know- 
ledge of  the  operator,  who  hardly  knew  that 
there  ought  to  be  an  artery  in  the  neck,  far  less 
could  he  appreciate  the  changes  which  would 
take  place  in  its  locality  from  disease. 

The  carotid  artery  being  placed  in  the  body  of 
the  tumour,  is  neither  very  rare  in  occurrence 
nor  very  difficult  to  explain.  It  is,  indeed,  a na- 
tural consequence  of  the  extension  of  the  tumour 
laterally;  yet  it  will  not  happen  in  every  tumour: 
it  will  only  occur  in  those  cases  where  the  con- 
sistence of  the  morbid  parts  is  soft.  When  the 
tumour  is  firm,  it  pushes  the  artery,  nervus  va- 
gus, and  internal  jugular  vein,  aside.  When  it 
is  soft,  these,  as  in  the  present  instance,  sink 
32 


250  ON  THE  SURGICAL  ANATOMY 


into  its  substance.  This  a fact  which  ought 
never  to  be  forgotten.  In  carcinoma  it  never 
takes  place;  in  fungus  hsematodes  it  sometimes 
occurs,  and  in  medullary  sarcoma,  I have  more 
than  once  proved  it  by  dissection  to  have  hap- 
pened. 

These  are  diseases  for  which  there  is  no  cure, 
except  the  use  of  the  knife;  hut  it  is  only  under 
certain  circumstances,  that  it  can  be  employed. 
It  is  only,  when,  from  the  limited  connexions  of 
the  tumour,  it  is  in  our  power  to  remove  com- 
pletely the  diseased  substance,  that  we  can  con- 
scientiously recommend  its  use.  Experience  daily 
proves,  that  if  the  smallest  particle  of  morbid 
matter  be  left  behind,  the  diseased  action  spreads 
from  it,  as  from  a centre,  the  wound  refuses  to 
heal,  the  sore  assumes  an  unhealthy  aspect,  it 
gleets  out  a profusion  of  abominably  fetid  ichor, 
and  the  patient  soon  dies,  worn  out  by  hectic. 
In  the  present  case,  the  tumour  might  undoubt- 
edly have  been  extirpated  at  its  commencement, 
and  that  without  much  danger;  but  procrastina- 
tion, and  the  employment  of  trifling  remedies, 
permitted  the  period  for  active  operation  to 
pass  by,  and  left  to  the  surgeon  only  the 
melancholy  task  of  witnessing  the  protracted 
sufferings,  and  miserable  death  of  the  patient:  a 
death  accelerated,  and  its  pain  aggravated,  by 
the  unskilful  wound  made  into  the  tumour.  Let 
this  be  impressed  on  the  mind,  for  it  will  enforce 


OF  THE  HEAD  AND  NECK. 


251 


the  necessity  of  having  recourse  to  prompt  and 
vigorous  measures  in  similar  cases. 

In  bronchocele,  even  when  the  tumour  is  very 
large,  and  even  where  the  carotid  is  imbedded  in 
its  substance,  we  may  palliate  either  by  external 
remedies,  or  by  tying  one  or  more  of  the  large 
arteries  which  nourish  the  morbid  parts;  but  in 
the  advanced  stage  of  carcinoma,  fungus  haema- 
todes,  and  medullary  sarcoma,  we  cannot  control 
the  growth  of  the  tumour.  The  arteries  be- 
longing to  it  are  not  enlarged  in  proportion  to 
its  bulk,  nor  would  tying  these,  destroy  the  spe- 
cific action  of  the  parts.  Extirpation  of  the 
whole  of  the  diseased  substance,  will  alone  se- 
cure the  patient  from  its  ravages;  but  this  it  is 
evident,  can  only  be  prudently  undertaken  in  the 
early  stage  of  the  complaint:  at  a time  when  the 
tumour  is  small,  and  free  from  adhesion  to  the 
important  vessels  and  nerves,  which  can  readily 
enough  be  ascertained,  in  the  same  way  that  we 
discover  whether  an  enlarged  concatenated  gland 
adheres  to  these  parts. 

Even,  however,  where  the  nature  of  the  disease 
has  been  early  ascertained,  where  the  tumour, 
is  still  small  and  moveable,  many  entertain  a 
dread  at  intermeddling  with  it;  a dread  founded 
on  preceding  failures,  arising  from  unskilful  man- 
agement, and  also  from  a review  of  the  parts 
with  which  the  tumour  is  in  contact.  It  is,  no 
doubt,  an  operation  dangerous  in  its  performance. 


252 


ON  THE  SURGICAL  ANATOMY 


but  it  has  been  safely  executed,  and  the  life  of 
the  patient  saved.  In  Paris,  the  right  lobe  of 
the  thyroid  gland  has  been  successfully  extir- 
pated by  Desault.  Freytag  informs  us,  that 
in  his  time,  this  gland  had  been  completely  re- 
moved, and  the  same  has  more  lately  been  done 
in  London.  Nor  was  this  more  than  we  would 
have  been  led  to  believe  and  expect,  from  the 
favourable  result  of  Mr.  Astley  Cooper’s  experi- 
ments on  the  inferior  animals. 

In  extirpating  this  gland,  an  incision  of  an 
eliptical  shape,  if  the  tumour  be  large,  or  if 
the  integuments  be  diseased,  is  to  be  made  over 
it,  with  the  long  diameter  directed  from  above  to 
below.  The  surface  of  the  swelling  is  next  to 
be  uncovered,  by  dissecting  back  the  integu- 
ments on  both  sides.  Then  the  finger  is  to  be 
insinuated  between  the  skin  and  the  muscles, 
pushing  it  upward  and  backward,  till  it  comes  in 
contact  with  the  thyroid  artery,  round  which  a 
ligature  is  to  be  passed  with  a blunt  needle.  In 
a similar  manner,  the  other  superior  thyroid  ar- 
tery, and  the  two  inferior  vessels,  are  to  be  se- 
cured, where  the  whole  gland  is  to  be  removed. 
By  these  ligatures  we  cut  off  the  circulation 
into  the  tumour,  and  consequently  are  left  at 
liberty  to  finish  the  operation,  by  cutting  the 
vessels  nearer  to  the  morbid  parts,  than  where 
the  threads  have  been  applied,  and  by  dividing 
the  sterno^hyoid,  and  thyroid  muscles,  above  and 


OF  THE  HEAD  AND  NECK. 


Q5S 


below  the  tumour,  which  is  afterward  to  be  de- 
tached from  the  trachea  and  gullet,  by  cautious 
working  with  the  fingers.  In  this  way,  we  may 
remove  one  or  both  lobes  of  the  thyroid  gland; 
but  the  operation  is  difficult,  tedious,  and  not 
without  danger.  Where  this  gland  is  enlarged, 
it  descends  into  the  angular  space,  just  above  the 
sternum,  and  comes  in  contact  with  the  arteria 
innominata,  to  which  I have  seen  it  adhere. 

W hen  the  parts  with  which  an  enlarged  thyroid 
gland  is  in  contact,  are  attended  to,  we  shall  not 
wonder  much,  that  the  extirpation  of  this  gland  is 
rarely  recommended.  In  front,  it  is  covered  with, 
and  bound  down  by  the  sterno-hyoid  and  thyroid 
muscles;  when  it  descends  low,  it  touches  the  arteria 
innominata;  on  the  left  side,  it  is  in  contact  with 
the  gullet,  and  lies  over  the  branches  of  the  recur- 
rent nerve;  and  on  both  sides,  when  it  extends  a 
little  further  out,  it  touches  the  carotid  artery,  the 
jugular  vein,  and  the  visceral  nerves.  To  those, 
therefore,  who  are  accustomed  to  do  every  thing 
with  the  knife,  the  extirpation  of  the  thyroid 
gland  must  appear  a formidable  operation;  but  to 
one  who  knows  where  to  use  the  scalpel,  and 
where  to  substitute  the  fingers,  the  removal  of  the 
thyroid  gland,  although  hazardous,  does  not  ap- 
pear impracticable. 

Albueasis  has  related  a case,  where  in  extirpat- 
ing a bronchocele,  the  large  cervical  vessels  were 
divided.  The  patient  died  fyom  excessive  hse- 


'254 


ON  THE  SURGICAL  ANATOMY 


morrhage.  When  we  remember  the  rudeness  of 
anatomical  knowledge  among  the  Arabians,  their 
ignorance  of  the  true  nature  of  the  circulation; 
and  when  we  add  to  these,  the  size  of  the  vessels 
in  the  vicinity  of  such  a tumour,  we  shall  not  feel 
surprised  at  the  result  of  this  operation:  nor  can 
we,  with  justice,  from  its  fatal  issue,  argue  the 
impropriety  of  cutting  out  a diseased  thyroid 
gland.  Palfin*  also  informs  us,  that  a young  lady 
died  during  the  extirpation  of  a bronchocele. 

Prosser  reprobates  the  excision  of  this  organ, 
and  adduces  the  cases  of  extirpation  of  the  thyroid 
gland,  witnessed  by  Gooch,  to  prove  the  impro- 
priety of  the  operation.  In  the  first  case  wnich 
Gooch  saw,  the  patient  was  in  a very  unfavoura- 
ble state.  The  person  was  reduced  to  extreme 
debility  by  the  disease,  and  weakness  was  still 
further  increased,  by  the  profuse  haemorrhage 
which  accompanied  the  removal  of  the  morbid 
parts.  Under  circumstances  such  as  these,  we 
need  not  be  surprised  that  the  patient  died  within 
eight  days  after  the  excision  of  the  gland,  and 
more  especially,  when  we  learn  that  during  all 
that  time,  the  bleeding  was  never  completely  re- 
strained. 

In  the  other  case,  also  witnessed  by  Gooch,  the 
young  lady  lost  a considerable  quantity  of  blood 
during  the  operation;  but  in  this  instance,  her  life 
was  saved  by  the  assistants  keeping  up  a constant 

* Palfin  Anatom,  tout.  ii.  page  513. 


OP  THE  HEAD  AND  NECK. 


255 


pressure  with  the  fingers  on  the  divided  vessels, 
for  nearly  eight  days  after  the  removal  of  the 
tumour.  Gooch  adds,  that  in  this  case,  the  sur- 
geon was  foiled  in  his  attempts  to  secure  the  ves- 
sels by  ligature. 

These  are  the  cases  from  which  Prosser  con- 
cludes, that  on  no  account,  ought  the  thyroid 
gland  to  be  removed  by  operation.  If,  however, 
we  attend  to  even  the  imperfect  account  which  is 
given  of  them,  we  shall  at  once  be  convinced,  that 
Prosser,  misled  by  an  abuse  of  the  operation, 
inferred  its  inexpediency  in  every  case.  In  both 
of  these  instances,  the  operation  without  doubt, 
was  most  injudiciously  performed.  It  has  ap- 
peared, that  in  both  cases  the  surgeon  trusted  to 
securing  the  arteries  after  the  removal  of  the 
tumour;  a plan  by  which  the  haemorrhage  would 
unquestionably  be  increased,  by  which  the  opera- 
tion would  be  protracted,  and  the  operator  embar- 
rassed. Had  he,  on  the  contrary,  secured  the 
four  arteries  before  he  attempted  to  remove  the 
tumour;  and  had  he  then  torn  the  diseased  parts 
from  their  attachments,  in  place  of  using  the  knife 
in  separating  them,  there  is  every  reason  to  be- 
lieve, that  in  the  last  case,  at  least,  there  would 
have  been  but  little  haemorrhage.  But  even  had 
this  plan  been  adopted  in  the  first  case,  the  event 
would  have  been  doubtful.  For  independently  of 
the  injudicious  performance  of  the  operation  in 
this  instance,  the  probability  is,  that  the  patient 


256 


ON  THE  SURGICAL  AN VTOMY 


would  have  died  from  the  mere  effects  of  the  irri- 
tation produced  on  the  debilitated  frame,  by  the 
removal  of  the  tumour;  but  when  to  this,  we  add 
a profuse  bleeding  during  the  operation,  and  a con- 
secutive haemorrhage,  the  event  must  necessarily, 
even  in  a stronger  person,  have  been  fatal.  From 
the  first  c:ise,  therefore,  we  can  hardly  draw  any 
fair  conclusion;  and  from  the  second,  the  only  in- 
ference we  can  draw,  is,  that  eventually  the  ope- 
ration  may  succeed,  even  where  the  extirpation 
of  the  tumour  has  been  very  injudiciously  accom- 
plished. 

Wilmer,  in  his  Essay  on  Bronchocele;  says, 
“when  we  reflect  upon  the  situation  of  the  thy- 
roid gland,  and  consider  its  numerous  arteries, 
which  increase  in  diameter  in  proportion  to  the 
enlargement  of  the  part,  we  shall  not  be  surprised 
at  the  difficulties  that  must  attend  its  extirpation 
in  a diseased  state,  and  the  danger  there  ever 
must  be  of  incurring  a fatal  haemorrhage.”* 
These  are  the  notions  entertained  by  all  who  re- 
probate this  operation,  but  they  are  founded  on  a 
mistake  in  anatomy.  A diseased  thyroid  gland 
really  derives  all  its  blood  from  four  arteries;  if, 
therefore,  the  surgeon  secure  these,  he  will,  in  de- 
taching the  morbid  parts,  have  nothing  further 
to  dread  from  bleeding  arteries. f By  venous 

* Wilmer’s  Cases  in  Surgery,  p.  243 

t Tlie  thyroid  gland  generally  receives  its  supply  of  blood  from  four 
vessels,  but  we  sometimes  find  a fifth  sent  to  it  by  the  arteria  innominata. 
Where  this  anomalous  vessel  exists,  it  will  usually  be  found  entering  the 


OP  THE  HEAD  AND  NECK. 


257 


haemorrhage,  he  may  still  be  incommoded,  but  it 
will  easily  be  checked.  Where,  however,  he 
employs  the  knife,  and  trusts  to  tying  the  arteries 
after  he  has  divided  them,  he  will  unquestionably 
experience  all  the  difficulty,  and  the  patient  will 
run  all  the  hazard,  that  Gooch’s  did.  The  life 
of  the  patient  will  be  saved,  “only  by  having  a 
succession  of  persons,  to  keep  a constant  pressure 
upon  the  bleeding  vessels  day  and  night,  for  near 
a week,  with  their  fingers  upon  proper  com- 
presses, after  the  operator  had  been  repeatedly 
disappointed  in  the  use  of  the  needle  and  liga- 
ture.”* 


Having  in  succession,  attended  to  the  relation 
of  the  different  parts  in  the  lower  and  middls 
regions  of  the  neck,  I am  next  led  to  inquire  into 
those  parts  which  lie  above  the  digastric  muscle. 
But  here  the  muscles,  glands,  vessels,  and  nerves, 
are  so  much  interwoven  with  one  another,  and  so 
perplexed  in  their  relations,  that  I hardly  know 
how  to  explain  them.  Description  cannot  com- 
municate a clear  idea  of  their  connexions,  it  can 
only  present  a mere  sketch;  a rough  outline  of 

cross  slip  of  the  gland,  just  on  the  fore  part  of  the  trachea.  This  artery 
sometimes  supplies  the  place  of  one  of  the  regular  thyroid  branches.  Jn 
extirpating  the  thyroid  gland,  these  facts  must  be  recollected. 

* Gooch’s  Med.  and  Chir.  Obs.  p.  130. 

33 


258 


ON  THE  SURGICAL  ANATOMY 


the  most  prominent  points.  The  details  must  be 
studied  on  the  dead  body:  for  it  is  by  dissection 
alone  that  the  student  can  hope  to  make  himself 
familiar  with  surgical  anatomy.  Even  the  best 
and  most  spirited  descriptions,  convey  but  a very 
imperfect  idea  of  the  structure,  and  such  an  idea, 
as  no  one  would  think  of  employing  as  a substitute 
for  actual  dissection,  more  especially  about  the 
angle  of  the  jaw.  The  few  following  remarks 
are,  therefore,  to  be  considered  as  hints,  to  be 
read  preparatory  to,  or  while  examining  the  ana- 
tomy of  the  angle  of  the  jaw,  on  the  recent  sub- 
ject. As  the  relation  of  these  parts  is  considera- 
bly influenced  by  the  position  of  the  cranium,  it 
will  be  necessary  to  say  a few  words,  respecting 
the  mechanism  of  the  skull. 

As  the  cranium  is  attached  to  the  spine,  con- 
siderably behind  the  axis  of  the  head,  a vacuity  is 
left  between  the  front  of  the  vertebrse  and  the 
inner  surface  of  the  lower  jaw  bone.  In  a fully 
grown  adult,  the  base  of  whose  skull  is  placed 
parallel  to  the  horizon,  the  surface  of  the  teeth 
in  the  upper  jaw  hone  is  generally  not  much  either 
above  or  below  the  line  of  the  foramen  magnum. 
By  this  position,  and  by  the  concavity  of  the 
roof  of  the  month,  a sufficient  space  is  left  between 
the  spine  and  the  lower  jaw  to  give  lodgement 
and  protection  to  the  tongue,  also  to  some  of  the 
large  vessels,  nerves,  and  important  glands. 
Between  the  mastoid  process  of  the  temporal 


or  THE  HEAD  AND  NECK- 


259 


bone,  and  the  ascending  plate  of  the  maxilla  infe- 
rior, there  is  only  the  transverse  diameter  of  the 
external  auditory  sinus  interposed.  In  a well- 
formed  jaw  the  ascending  plate  is  about  two  in- 
ches in  length,  and  the  angle  of  the  jaw  is  situat- 
ed about  an  inch  anterior  to  the  cervical  vertebra. 
A little  before  the  root  of  the  mastoid  process, 
and  a little  nearer  to  the  centre  of  the  base  of 
the  skull,  the  styloid  process  begins.  From  the 
inclination  forward  of  the  styloid  process  its  distal 
extremity  comes  to  be  hid  behind  the  ascending 
plate  of  the  jaw-bone,  although  its  root  be  placed 
considerably  behind  it.  This  is  a character  pe- 
culiar to  the  adult;  it  is  one  which  neither  exists 
in  childhood,  nor  is  to  be  found  in  an  edentulous 
subject. 

When  the  base  of  the  skull  is  placed  parallel 
to  the  horizon,  and  when  the  muscles  about  the 
throat  are  in  an  easy  state  of  relaxation,  the 
pharynx  is  flattened,  and  the  back  part  of  the 
larynx  rests  on  its  posterior  surface,  which  is  in 
close  contact  with  the  face  of  the  spine.  In  this 
position  of  the  head  the  os-hyoides  is  nearly  as 
high  as  the  margin  of  the  lower  jaw-bone.  Hence 
the  posterior  belly  of  the  digastric  muscle  has 
only  a slight  declination,  while  the  anterior  runs 
almost  in  a straight  line  forward. 

In  tracing  the  relation  of  the  parts  about  the 
angle  of  the  jaw,  the  preferable  plan,  I believe. 


260 


ON  THE  SURGICAL  ANATOMY 


will  be  to  begin  behind,  and  notice  them  in  suc- 
cession forward. 

The  spinal  accessory  nerve  appears  between 
the  transverse  process  of  the  atlas  and  the  inter- 
nal jugular  vein.  It  lies  in  such  a situation  that 
it  may  be  exposed  by  an  incision  made  along  the 
anterior  margin  of  the  sterno-mastoid  muscle, 
just  opposite  to  the  transverse  process  of  the 
atlas.  Lower  than  this  the  nerve  is  completely 
covered  by  the  muscle,  which  it  finally  perforates 
to  reach  the  trapezius  muscle.  Nearer  to  the 
angle  of  the  jaw  than  the  spinal  accessory  nerve, 
but  in  contact  with  it,  the  jugular  vein  is  found; 
next  to  it,  we  see  the  lingual  nerv.e,  and  then  the 
internal  carotid  artery.  The  external  carotid 
is  separated  from  the  internal,  which  is  the  deep- 
est seated,  by  the  styloid  process;  or,  where  that 
process  is  very  short,  by  the  ligament  wrhich  is 
extended  from  it  to  the  appendix  of  the  os- 
hyoides. 

A little  lower  than  the  angle  of  the  jaw  the 
occipital  artery  generally  arises  from  the  external 
carotid.  The  occipital  artery  in  its  course  slants 
upward  and  outward,  traversing  the  internal 
carotid,  the  nervus  vagus,  the  lingual  nerve, 
and  the  internal  jugular  vein;  after  which  it 
slips  in  behind  the  digastric  muscle,  and  passes 
round  the  root  of  the  mastoid  process,  just  above 
the  transverse  process  of  the  atlas.  From  be- 
tween the  internal  carotid  and  jugular  vein,  but 


OF  THE  HEAD  AND  NECK. 


261 


a little  lower  than  the  line  of  the  lower  jaw,  the 
lingual  nerve  makes  its  appearance.  It  instantly 
turns  rather  abruptly  forward,  and  in  doing  this, 
it  often  hooks  round  the  origin  of  the  occipital 
artery.  Just  where  accomplishing  this  turn,  it 
sends  off  the  ramus  descendens  noni,  after  which 
it  continues  forward,  passing,  in  its  course,  be- 
hind the  termination  of  the  fascial  vein,  but  be- 
fore the  external  carotid  artery.  A little  near- 
er to  the  os-hyoides  it  slips  behind  the  digastricus 
and  the  stylo-hyoideus,  lying  between  them  and 
the  stylo-glossus  muscle. 

The  lingual  nerve  is  in  absolute  contact  with 
the  root  of  the  lingual  artery,  but  when  they 
have  reached  the  side  of  the  tongue  they  are 
separated  by  the  interposition  of  the  hyo-glossus 
muscle,  which  continues  between  them  forward  to 
the  origin  of  that  muscle  from  the  body  of  the 
os-hyoides. 

Till  the  artery  arrives  at  the  junction  of  the 
body  with  the  horn  of  the  hyoid  bone,  it  is  cov- 
ered by  the  skin,  by  the  fibres  of  the  platysma 
myoides,  the  cervical  fascia,  the  lingual  nerve, 
and  the  hyo-glossus  muscle.  When  it  turns  for- 
ward and  plunges  deep  into  the  substance  of  the 
tongue,  and  begins  to  be  broken  down  into  bran- 
ches, it  is  covered  by  new  parts.  When  we  now 
cut  to  it  from  below  the  chin,  we  require  to 
divide  the  skin,  platysma  myoides,  fascia,  the 
anterior  belly  of  the  digastric,  the  mylo-hyoideus, 


£>62 


ON  THE  SURGICAL  ANATOMY 


and  the  genio-hyoideus.  By  an  incision  through 
these,  the  artery  will  he  brought  into  view,  ly- 
ing between  the  genio-glossas  and  the  lingualis 
muscle. 

This  view  of  the  locality  of  the  lingual  artery 
puts  it  beyond  a doubt,  that  the  proper  place  to 
expose  the  vessel,  when  we  wish  to  pass  a liga- 
ture round  it,  is  while  it  is  running  parallel  to 
the  horn  of  the  os-hyoides.  There,  it  is  com- 
paratively superficial,  and  consequently  easily 
reached;  it  is  neither  entangled  among  many  mus- 
cles, nor  connected  with  more  than  one  large 
nerve.  It  is  rare,  however,  that  this  operation 
requires  to  be  performed;  yet,  when  we  recollect 
that  many  patients  have  been  allowed  to  die  a 
lingering  death,  when  the  tongue  has  been  dis- 
eased, purely  from  the  dread  of  the  bleeding 
which  would  arise  from  extirpation  of  this  organ, 
it  becomes  necessary  to  shew  the  command  which 
the  surgeon  actually  has  over  the  lingual  arte- 
ries. The  older  operators  imagined  that  it  would 
be  necessary  to  tie  the  vessels  just  where  they 
were  divided;  but  the  known  difficulty  of  accom- 
plishing this  in  a deep  and  confined  cavity,  natu- 
rally made  them  timid. 

Mr.  Everard  Home  and  others  have  proved, 
that  portions  of  the  tongue  may,  with  the  great- 
est safety,  be  removed  by  ligature.  Yet  there 
are  cases,  in  which,  from  the  situation  of  the 
diseased  parts,  it  would  be  impracticable  to  apply 


OP  THE  HEAD  AND  NECK. 


263 


the  thread.  In  such  cases,  I hardly  think  it  too 
much,  when  I say,  that  the  morbid  parts  may  be 
extirpated  by  the  knife.  Have  not  we  seen,  that 
by  a superficial  and  safe  incision,  the  trunks  of 
the  lingual  arteries  may  be  tied  before  they 
have  given  off  any  important  branches.  Now,  I 
would  inquire,  if  this  has  been  done,  what  have 
we  to  dread?  not  the  bleeding  surely,  for  that 
we  have  controlled;  not  the  loss  of  the  tongue, 
for  that  organ,  we  without  hesitation,  remove 
with  the  ligature;  and  we  know,  that  by  disease, 
the  whole  of  it  may  be  destroyed  without  much 
detriment.* 

When  I thus  argue  the  practicability  of  extir- 
pating the  tongue  with  the  knife,  I should  be 
sorry  to  be  misunderstood,  or  to  have  it  supposed, 
that  I would,  when  the  ligature  could  be  em- 
ployed, prefer  the  scalpel.  On  the  contrary,  I 
have  used  the  ligature  in  removing  a considera- 
ble portion  of  the  tongue,  and  would  still  con- 
tinue to  employ  it  whenever  I could  apply  it. 
But  every  surgeon  may  have  seen  cases,  where 
from  the  situation  of  the  disease,  he  could  not 
use  a ligature.  I have  myself  seen  three,  under 
the  care  of  other  surgeons,  who,  after  the  ap- 
plication of  many  and  various  remedies,  local 
as  well  as  general,  had  the  mortification  to  see 
their  patients  daily  sinking  under  the  extension 
of  the  disease,  which  began  at  the  root  of  the 


* Riolan  anil  Portal. 


264 


ON  THE  SURGICAL  ANATOMY 


tongue  and  proceeded  forward.  In  such  cases, 
at  least,  I would,  after  having  tied  the  trunks  of 
the  lingual  arteries,  be  inclined  to  try  the  ef- 
fect of  extirpating  the  morbid  parts  with  the 
knife. 

It  is  not  the  relations  of  the  trunk  of  the  lin- 
gual artery  alone  which  the  student  ought  to 
make  himself  acquainted  with.  He  will  do  well 
to  study  the  position  of  the  arteria  ramna  in 
respect  to  the  frcenum  linguse.  This  informa- 
tion will  teach  him  the  impropriety  of  pointing 
the  scissors  upward  and  backward,  when  snip- 
ping the  frcenum,  an  operation,  oftener  per- 
formed than  needed.  He  will  learn  that  the 
ranular  artery  lies  just  above  the  attachment  of 
the  frcenum,  so  that  if  he  would  avoid  it,  he  must 
turn  the  points  of  the  scissors  rather  downward; 
if  he  do  not,  the  artery  will  probably  suffer.  As 
the  consequences  of  injuring  this  vessel,  and  the 
plan  of  treatment  are  very  fully  related  in  differ- 
ent works,  I refer  to  them. 

As  the  os-hyoides  is  nearly  as  high  in  the  throat 
as  the  jaw  bone,  when  the  base  of  the  cranium  is 
placed  parallel  to  the  horizon,  the  mylo-hyoideus 
muscle  has  very  little  descent.  When,  therefore, 
the  submaxillary  gland  is  cut  away,  a consider- 
able cavity  is  left  between  the  side  of  the  tongue 
and  the  lower  jaw  bone.  The  roof  of  this  hollow 
is  formed  toward  the  chin  by  the  mylo-hyoideus, 
and  nearer  to  the  angle  of  the  jaw  by  the  hyo- 


OF  THE  HEAD  AND  NECK.  265 

glossus,  which  is  intersected  by  the  stylo-glossus. 
Between  the  carotid  arteries  and  this  cavity,  the 
ligament  of  the  angle  of  the  jaw  is  interposed. 
Above  the  hyo-glossns  muscle,  the  lingual  branch 
of  the  third  division  of  the  fifth  pair  of  nerves 
runs  towards  the  tongue. 

In  this  cavity,  the  submaxillary  conglomerate 
and  conglobate  glands  are  lodged,  along  with  the 
fascial  artery  and  vein,  together  with  the  branches 
sent  off  from  them  before  they  mount  on  the 
face.  In  this  position  of  the  head,  little  of  the 
submaxillary  gland  is  exposed,  it  is  almost  entirely 
covered  by  the  body  of  the  jaw  bone.  It  is  all, 
indeed,  nitched  in  between  the  two  bellies  of  the 
digastric  muscle  and  the  jaw7  bone.  The  fascial 
artery  at  its  origin  is  very  little  lower  than  the 
angle  of  the  jaw,  hence,  it  soon  becomes  closely 
connected  with  the  submaxillary  gland;  but  be- 
fore it  does  so,  it  gives  off  the  ascending  palatine 
and  the  tonsillitic  branches.  It  then  mounts  over 
the  subinaxillary  gland,  lying  in  a sulcus,  formed 
for  its  reception  The  fascial  vein  descends  along 
the  side  of  the  gland  nearest  to  the  ear,  and 
empties  itself  generally  into  the  internal  jugular 
vein,  just  below  the  edge  of  the  digastric  muscle. 

Behind  this  cavity,  deep-seated,  and  nearly 
opposite  to  the  root  of  the  alveolar  process  of 
the  second  molar  tooth,  the  tonsil  lies  sunk  into 
the  recess  formed  between  the  pillars  of  the 
fauces.  It  is  situated  in  the  angle  between  the 
34 


266 


ON  THE  SURGICAL  ANATOMY 


stylo-glossus  and  stylo-pharyngeus,  and  is  cover- 
ed by  the  fibres  of  the  palato-pharyngeus  muscle- 
It  is  supplied  by  an  artery  arising  sometimes 
from  the  lingual,  but  generally  from  the  labial 
artery,  just  where  that  vessel  is  passing  along 
the  insertion  of  the  stylo  glossus  muscle.  The 
tonsillitic  artery  is  therefore  short,  and  it  is  also 
generally  small,  but  where  the  tonsil  was  dis- 
eased, I have  seen  its  nutrient  vessel  larger  con- 
siderably than  a crow  quill. 

A little  higher  than  the  origin  of  the  labial 
artery,  the  external  carotid  is  nearly  opposite  to 
the  tonsil,  but  the  internal  lies  a little  behind  the 
natural  situation  of  that  gland.  The  glosso- pha- 
ryngeal nerve  which  escapes  from  between  the 
external  and  internal  carotid  arteries,  just  at  the 
origin  of  the  stylo  pharyngeus  muscle,  is,  as  well 
as  that  muscle  and  the  stylo-glossus,  completely 
sunk  behind  the  jaw  bone. 

These  are  the  relations  which  the  different 
parts  bear  to  each  other,  and  to  the  jaw  bone  in 
the  full  grown  adult,  in  whom  the  head  is  neither 
inclined  backward  nor  forward.  By  bending  back 
the  head,  the  position  of  all  the  parts  becomes 
materially  altered;  but  none  are  more  changed  than 
the  submaxillary  gland,  the  fascial  artery  and 
vein.  These  parts,  which  in  the  natural  position 
of  the  head,  lie  retired  behind  the  body  of  the 
jaw  bone,  are  much  exposed  by  the  elevation  of 
the  chin.  The  cavity  which  formerly  existed  be- 


OP  THE  HEAD  AND  NECK. 


267 


tween  the  maxilla  and  the  mylo-hyoideus,  is  much 
reduced  in  size,  and  its  contents  are  brought  out 
from  behind  the  jaw  bone.  They  are  rendered 
more  accessible  where  we  wish  to  extirpate  them. 
These  changes  ought  to  be  remembered,  when 
about  to  remove  a tumour  from  this  region,  be- 
cause the  operation  will  be  materially  facilitated 
by  placing  the  head  in  a proper  position.  The 
frequency  of  such  tumours  will  be  readily  estima- 
ted by  one  who  knows  the  number  of  conglobate 
glands  which  are  clustered  round  the  submaxillary 
salivary  gland,  and  who  remembers  how  liable 
these  are  to  contamination  from  sores  in  the  neigh- 
bourhood. 

The  salivary  glands  are  very  rarely  swelled, 
the  lymphatic  ones  very  frequently,  but  it  for- 
tunately happens,  that  these  glandular  swellings 
are  not  often  of  such  a nature  as  to  require  ex- 
cision. They  are  usually  scrophulous,  running 
their  course  slowly,  but  at  length  suppurating. 
Sometimes,  however,  the  tumour  is  of  a less 
tractable  nature;  for  sometimes  it  arises  from  ab- 
sorption of  specific  pus,  from  ulceration  of  the  lip, 
or  of  the  cheek,  or  below  the  tongue. 

A tumour  of  this  species,  may,  in  the  early 
stage  of  the  complaint,  be  removed  with  tolerable 
ease;  but  where  it  has  been  neglected  from  the 
compression  and  matting  of  the  parts  in  the  vi- 
cinity, the  excision  is  attended  with  greater  dif- 
ficulty and  more  danger.  Extirpation  of  the 


268 


ON  THE  SURGICAL  ANATOMY 


tumour  is  only,  indeed,  practicable,  when  the  mor- 
bid mass  is  defined  and  moveable. 

If  it  has  become  fixed,  it  will,  by  the  resist- 
ance of  the  fascia  and  platysma  myoides,  be  pre- 
vented from  extending  downward;  it  will  become 
pushed  upwards,  forcing  its  way  into  the  mouth 
from  below  the  tongue.  Here,  however.  I would 
caution  the  surgeon  not  to  mistake  the  fulness  na- 
turally produced  by  the  sublingual  gland  for  a tu- 
mour; a fulness  which  is  much  incre  sed  when  the 
submaxillary  glands  are  enlarged.  The  granulat- 
ed surface,  and  doughy  feel  of  the  salivary  gland, 
may  assist  him  in  distinguishing  it  from  a part 
of  the  diseased  mass,  which  generally  pushes  the 
sublingual  gland  towards  the  tongue,  making 
thus  a way  for  itself  into  the  mouth,  between  the 
displaced  sublingual  gland  and  the  gum.  Thus, 
a tumour,  which  superfically  has  only  a small 
appearance,  may  have  formed  deep-seated  con- 
nexions, which  would  forbid  any  attempt  to 
operate. 

Such  a tumour  will  be  in  contact  on  the  side 
nearest  to  the  chin  with  the  digastric  muscle; 
above  it  will  touch  the  mvlo-hyoideus,  and  be- 
hind that  muscle,  it  will  be  absolutely  in  contact 
with  the  lingual  branch  of  the  fifth  pair  of 
nerves,  which  is  interposed  between  it  and  the 
sublingual  gland;  and  posteriorly,  it  will  be  more 
or  less  connected  with  the  primary  branches  of 
the  carotid  artery,  and  with  the  side  of  the  pha- 


or  THE  HEAD  AND  NECK.  5269 

rynx.  Even  in  the  simplest  tumour,  the  morbid 
parts  are  closely  connected  with  the  labial  artery 
and  vein,  for  these  vessels  are  generally  more 
or  less  buried  in  the  diseased  substance;  and  in 
planning  our  operation,  we  must  decide  on  sa- 
crificing them.  But  when  the  tumour  has  ex- 
tended so  far  as  to  have  come  in  contact  with, 
and  become  fixed  to  the  other  parts  which  have 
been  mentioned,  the  difficulty  of  dissecting  away 
all  the  diseased  substance,  will  be  insuperable. 

Mrs.  M‘Donald?s  was  a very  deplorable  case 
of  disease  in  the  salivary  and  conglobate  glands 
below  the  jaw.  From  ear  to  ear,  her  throat 
was  girded  by  a chain  of  tumours,  some  inter- 
woven with  the  muscles  and  vessels,  and  others 
wedged  into  the  fauces,  but  all  so  clustered,  so 
much  matted  among  the  surrounding  parts,  and 
so  widely  connected,  as  to  defy  any  operation. 
When  I first  saw  her,  she  was  gasping  for  breath, 
and  the  anxiety  and  leaden  hue  of  the  counte- 
nance bespoke  the  severity  of  the  struggles  for 
air,  and  its  great  deficiency. 

Nothing  relieved  her  but  the  occasional  burst- 
ing of  small  kernel  like  cysts,  which  pervaded 
the  more  solid  texture,  and  which  discharged 
trifling  quantities  of  glutinous  fluid  into  the 
mouth  streaked  with  blood.  Blisters,  and  the 
other  remedies  employed,  had  no  effect;  an  ope- 
ration was  out  of  the  question;  earnestly,  there- 
fore, as  we  desired  to  alleviate  her  sufferings, 


270 


ON  THE  SURGICAL  ANATOMY 


we  could  do  no  more,  than  at  each  visit  wit- 
ness her  distress,  and  regret  the  impotence  of 
our  art. 

In  deciding  on  the  expediency  of  extirpating 
a tumour  from  below  the  jaw,  we  may  be  con- 
siderably assisted  by  ascertaining  the  origin  of 
the  disease,  discovering  whether  it  be  idiopath- 
ic, or  dependent  on  absorption  from  some  sore 
in  the  vicinity,  the  length  of  time  the  swelling 
has  continued,  and  the  rapidity  of  its  growth. 
If  it  has  been  produced  by  absorption  from  a 
specific  sore,  if  it  has  been  of  short  continuance 
and  slow  in  its  actions,  and  if  it  still  continues 
as  moveable  as  could  be  expected,  considering 
the  effect  of  the  fascia,  we  may  undertake  its 
removal.  But  if,  on  the  other  hand,  it  has  dated 
its  origin  from  a distant  period,  has  been  brisk 
in  its  actions,  and  has  become  fixed  to  the  mus- 
cles, vessels,  and  nerves  in  the  neighborhood,  it 
would  be  foolish  to  attempt  its  extirpation.  Be- 
cause, although  from  the  resistance  of  the 
fascia,  the  tumour  externally  may  not  appear 
formidable,  yet,  internally  it  may  have  extend- 
ed its  connexions,  and  embraced  parts  from 
which  it  could  not  possibly  be  cleared.  To  at- 
tempt, therefore,  its  removal  under  such  circum- 
stances, would  be  fruitless;  we  might,  indeed,  cut 
away  what  we  saw  of  the  diseased  substance, 
but  a portion  would  still  remain  behind. 


OP  THE  HEAD  AND  NECK.  271 

Before  resolving  on  the  extirpation  of  a can- 
cerous lip,  the  surgeon  ought  most  carefully  to 
examine  the  state  of  the  submaxillary  absorbent 
glands.  This  he  ought  to  do  in  every  case;  but 
where  the  disease  is  in  an  advanced  stage,  and 
seated  in  the  lower  lip,  he  ought  to  be  doubly 
watchful.  From  inattention  to  this  point,  I have 
more  than  once  seen  the  disease,  after  the  extir- 
pation of  a cancerous  lip,  reproduced  below  the 
jaw;  a gland  which  had  been  contaminated  there 
was  overlooked,  it  continued  to  increase  in  size, 
and,  before  the  death  of  one  of  the  patients,  which 
was  occasioned  by  a different  complaint,  the 
tumor  had  acquired  such  a size  as  to  give  rise 
to  considerable  inconvenience. 

When  a tumour  is  to  be  extirpated  below  the 
jaw,  the  operator  will  most  easily  accomplish  his 
purpose,  by  placing  the  patient  on  a chair,  and 
reclining  his  head  on  the  breast  of  an  assistant, 
who  ought  to  stand  behind  him.  The  jaw  of  the 
patient  must  be  kept  closed,  while  the  surgeon  by 
a crucial  incision  through  the  skin,  platysma  my- 
oides,  and  fascia,  exposes  the  tumour,  which  he  is 
fully  to  uncover,  by  dissecting  the  flaps  to  a side. 
Next  he  is  to  push  his  fingers  between  the  swell- 
ing and  the  surrounding  parts,  working  his  way 
among  the  cellular  membrane,  till,  at  the  lower 
end  of  the  tumour,  he  feels  the  pulsation  of  the 
labial  artery.  By  insinuating  the  finger  along 
the  tumour,  following  the  course  of  the  vessel,  he 


272  ON  THE  SURGICAL  ANATOMY 

will  ascertain  its  connexions.  If  he  find  that  the 
artery  is  not  imbedded  in  the  substance  of  the 
swelling,  he  may,  by  continued  working  with  the 
fingers,  insulate  and  remove  the  tumour,  without 
injuring  the  trunk  of  the  labial  artery.  Gene- 
rally, however,  he  will  find  the  vessel  so  closely 
connected  with  the  morbid  mass,  that  it  would  be 
out  of  the  question  to  attempt  their  separation. 
Here  the  plan  to  be  pursued  is  evident.  A liga- 
ture is  to  be  passed  round  the  labial  artery,  just 
where  entering  into,  and  passing  out  from  the 
diseased  gland,  and  next  the  vessel  is  to  be 
divided  at  both  places,  nearer  to  the  gland  than 
where  the  threads  have  been  applied. 

On  the  dead  subject  I have  found  it  easiest 
to  detach  the  gland  when  I began  its  separation 
nearest  to  the  angle  of  the  jaw,  and  proceeded 
towards  the  chin,  near  to  which  the  submental 
artery  will  require  to  be  snipped  across.  It  is 
demonstrable,  that  in  this  way  the  submaxillary 
conglomerate  gland  will  be  torn  away  along  with 
the  tumour;  but  this,  so  far  from  proving  disad- 
vantageous, will  add  to  the  security  of  the  patient. 
But  let  the  surgeon  remember,  that  in  many  sub- 
jects the  submaxillary  and  sublingual  glands  are 
connected  by  a communicating  slip,  which  will 
require  to  be  cut  across,  else  the  sublingual  gland 
will  be  pulled  away,  which,  to  say  the  least,  would 
be  generally  unnecessary. 

The  salivary  glands,  although  not  so  often  dis- 


OF  THE  HEAD  AND  NECK.  273 

eased  as  the  lymphatic  glands  which  are  clustered 
around  them,  are  nevertheless,  sometimes  affected. 
For  instance,  they  are  subject  to  inflammation, 
producing  a painful  swelling  below  the  tongue, 
accompanied  with  interruption  of  the  secre- 
tions of  that  part  of  the  gland  which  is  inflam- 
ed. Resolution  or  induration  are  the  usual  ter- 
minations of  this  inflammation.  Gariot,  a late 
French  author,  on  the  diseases  of  the  mouth, 
conjectures  that  the  secreting  part  of  a gland  is 
incapable  of  suppurating;  when,  therefore,  an 
inflamed  gland  suppurates,  he  asserts,  that  the 
purulent  matter  is  formed  by  the  cellular  texture 
entering  into  the  composition  of  the  gland.  This, 
if  correct,  is  an  important  fact,  because,  as  the 
cellular  matter  is  the  medium  through  which  the 
blood-vessels  are  conducted  into  the  glandular 
substance,  it  follows,  that  if  the  former  be 
destroyed,  the  latter  also  must  decay,  and 
then  the  whole  or  a part  of  the  gland  must  die 
according  as  the  suppuration  has  been  general  or 
partial. 

The  salivary  glands  are  not  only  liable  to  be- 
come inflamed,  but  calculi  likewise  form  in  them. 
When  a concretion  has  formed  in  the  sublingual 
gland,  a chronic,  irregular,  and  dense  tumour  is 
produced  below  the  tongue.  The  disease  is 
readily  discovered  and  easily  cured.  The  foreign 
substance  is  to  be  extracted  by  an  incision  into 
the  gland,  just  by  the  side  of  the  frcenum  linguae 
35 


274 


ON  THE  SURGICAL  ANATOMY 


A calculus,  weighing  a drachm,  was  in  this  way 
easily  extracted. 

The  hard  tumour  occasioned  by  a concretion 
gives  rise  to  a considerable  inconvenience;  but 
obstruction  of  the  termination  of  the  sublingual 
duct  is  a more  dangerous,  because  a more  insidious 
complaint.  Its  commencement  is  marked  by  a 
small  and  painful  papilla  beneath  the  tongue, 
which  slowly  enlarges,  till  it  finally  presses  the 
tongue  firmly  against  the  roof  of  the  mouth,  injur- 
ing the  speech,  and  impairing  the  functions  of 
respiration  and  deglutition.  At  length  the  most 
prominent  point  of  the  tumour  bursts,  and  dis- 
charges a considerable  quantity  of  a transparent 
glary  fluid.  By  the  evacuation  of  the  fluid,  the 
tongue  recovers  its  natural  position,  every  incon- 
venience is  suddenly  removed,  and  the  patient 
flatters  himself  with  the  delusive  hope  that  he  will 
soon  be  cured.  Sometimes,  however,  the  com- 
plaint assumes  a more  alarming  appearance. 

Ehrlich  in  the  observations  collected  during 
his  travels,  relates  a curious  case  of  this  disease: 
“Un  jour  un  homme  demanda  a parler  a M. 
Cline.  On  le  fit  entrer  dans  Pantichambre:  tout 
a coup  M Cline,  entendit  tomber  quelque  chose 
et  des  plaintes  et  gemissemens  d’une  personne. 
En  ouvrant  la  port  il  vit  Phomme  en  question, 
etendu  parterre,  sans  connoissance  et  pret  a etouf- 
fer.  Cline  soupeonna  la  presence  d’une  corps 
stranger  dans  la  trach^e  artere,  et  se  disposoit 


OF  THE  HEAD  AND  NECK. 


275 


deja  >t  pratiquer  la  bronchotomie,  lorsqu’il  ap- 
percut  la  langue  du  malade  poussee  fortement  en 
arriere  par  une  grenouillette  qui  de  plus  faisoit 
saillie  au  dehors.  II  y plongea  une  lancette,  et 
donne  par  la  issue  a une  grande  quantite  de  pus 
et  de  lymphe. 

“Le  malade,  revenu  ^ lui,  declara  que  depuis 
long-terns  il  avoit  port£  une  tumeur  considerable 
sous  la  langue,  sans  en  etre  gen;  ni  en  parlant  ni  en 
respirant;  que  cette  tumeur,  pendant  le  peu  de  mi- 
nutes qu’il  avoit  attendu  dans  Fantichambre,  avoit 
acquis  tres  subitement  un  acroissement.  si  consi- 
derable qu’elle  1’auroit  infailleblement  etonffe  sans 
la  prompt  secours  que  M.  Cline  lui  avoit  donne. 

This  was  a peculiar  case,  generally  the  pro- 
gress of  the  tumour  is  slow,  and  it  bursts  before 
such  a size  as  in  the  present  instance  has  been 
acquired.  The  opening  seldom,  however,  con- 
tinues pervious  for  more  than  a few  days;  it 
slowly  closes,  again  a tumour  forms,  it  enlarges, 
bursts,  but  effuses  a smaller  quantity  of  fluid  than 
the  former  one,  and  the  tongue  returns  less  per- 
fectly to  its  situation  than  before.  The  sides 
of  the  sac  have,  now  begun  to  thicken,  and  the 
parts  in  the  vicinity  have  begun  to  swell.  The 
original  complexion  of  the  disease  is  about  to 
change,  yet  the  alteration  is  not  suddenly  accom- 
plished. The  collection  and  evacuation  of  fluid  is 
continued  for  a length  of  time;  but  after  each  suc- 
cessive discharge  the  patient  is  less  and  less 


276 


ON  THE  SURGICAL  ANATOMY 


relieved,  till  at  length  the  tumour  becomes  alto- 
gether solid.  Now  it  increases  more  rapidly, 
and  now  it  more  completely  displaces  the  tongue. 
Formerly  this  organ  had  only  been  pressed  against 
the  roof  of  the  mouth;  now  its  apex  is  reverted, 
so  that  it  presses  on  the  epiglottis,  disturbing 
breathing  and  swallowing  very  materially,  and 
about  this  time  the  tumour  begins  to  project  below 
the  jaw. 

The  nature  of  the  tumour  is  most  thoroughly 
ly  changed;  from  containing  a fluid,  it  has  be- 
come solid,  it  is  daily  enlarging,  and  we  can  now 
anticipate  no  spontaneous  alleviation  of  the  dis- 
ease, such  as  took  place  in  the  former  period. 
This  is  a disease,  which  in  the  early  stage,  is 
easily  cut  short,  but  when  permitted  to  gain 
ground,  its  treatment  becomes  more  complicated; 
and  after  the  tumour  becomes  solid,  it  baffles 
every  attempt  at  cure.  This  ought  to  be  firmly 
impressed  on  the  mind,  for  here  it  is  the  duty  of 
the  surgeon,  to  decide  early  on  the  plan  he  is  to 
follow,  and  having  once  resolved,  it  is  his  busi- 
ness to  act  up  to  his  intentions  with  promptitude. 

Before  the  sides  of  the  cyst  have  begun  to 
thicken,  the  treatment  is  exceedingly  simple. 
The  sac  is  to  be  treated  as  a sinus;  we  are  to 
plunge  a bistoury  into  it  behind;  are  to  open  it 
through  its  whole  extent;  are  to  irritate  its  inner 
surface,  to  produce  reunion  of  its  sides,  and  the 
destruction  of  its  glandular  function.  The  natu- 


OP  THE  HEAD  AND  NECK. 


277 


ral  bursting  of  the  sac,  or  the  mere  puncture, 
are  only  palliative.  Before  we  can  cure  the 
complaint,  the  callous  inner  surface  of  the  cyst 
must  be  fairly  exposed,  and  brought  into  a gran- 
ulating state,  by  the  use  of  stimulating  applica- 
tions, such  as  tincture  of  myrrh,  or  diluted  aq. 
potass.  The  sore  must  be  healed  from  the  bot- 
tom, otherwise  we  merely  teaze  the  patient,  and 
convert  a curable  into  an  incurable  complaint. 
Generally  so  soon  as  the  sides  of  the  sac  have 
begun  to  form  granulations,  the  further  use  of 
irritating  applications  is  to  be  given  up;  they  are 
now  detrimental,  in  so  far  as  they  tend  to  check 
the  formation  of  healthy  granulations. 

Where  the  surgeon  has  been  consulted  suffi- 
ciently early,  the  preceding  plan  of  treatment 
will  generally  prove  effectual,  but  where  the  dis- 
ease has  advanced  so  far,  as  to  have  induced  a 
considerable  degree  of  induration  about  the  ter- 
mination of  the  sublingual  duct,  then  the  plan 
advised  by  Gariot  must  be  adopted.  He  directs 
that  the  tumour  be  completely  opened  by  a cru- 
cial incision,  after  which  the  callous  sides  of  the 
cyst  are  to  be  cut  off  with  a bistoury.  The 
sponge  will  control  the  bleeding.  In  a few  days 
suppuration  commences,  granulation  soon  follows, 
and  the  wound  heals  up  progressively.* 

Pare  and  Tulpius,  after  opening  the  cyst,  ap- 
plied a heated  iron  to  its  inner  surface.  Dionis 

*Gariot  Traite  des  .Maladies  de  la  Bouplie,  p.  131. 


278  ON  THE  SURGICAL  ANATOMY 

touched  it  with  sulphuric  acid,  in  place  of  which 
M.  de  la  Faye  employed  the  caustic.  Wilmer  in 
one  instance,  passed  a seton  through  the  tumour 
which  not  inducing  sufficient  irritation,  was  with- 
drawn. He  then  removed  with  the  knife,  a cir- 
cular portion  of  the  cyst,  below  the  tongue  and 
next  used  the  caustic,  by  which  a radical  cure 
was  accomplished.* 

In  another  case  of  ranula,  where  the  tumour  was 
very  large,  and  projected  far  below  the  circle 
of  the  jaw,  he  made  an  incision  into  the  cyst 
from  below  the  chin,  removed  the  lower  part  of 
the  sac,  stuffed  the  wound  with  dry  lint,  which  he 
removed  on  the  fifth  day,  and  applied  the  pure  pot- 
assa  to  what  remained  of  the  sac.  In  a few  days 
the  slough  separated,  and  in  six  weeks  the  pa- 
tient was  cured. f I mention  this  case,  not  on 
account  of  any  peculiarity  in  the  principle  of 
treatment,  but  on  account  of  the  place  where 
the  incision  was  made  into  the  sac.  Where  the 
sublingual  gland  is  affected,  the  tumour  is  pre- 
vented by  the  mylo-hyoideus  from  descending  to- 
ward the  throat,  and  pushes  itself  into  the  mouth: 
where  the  submaxillary  gland  is  the  seat  of  the 
disease,  that  muscle  prevents  the  tumour  mount- 
ing into  the  mouth;  it  swells  below  the  chin. 
In  the  first  case,  therefore,  we  would  cut  into  the 
cyst,  just  below  the  tongue,  but  in  the  last,  we 


* Wilmer’s  Cases  in  Surgery,  p.  80.  t Ibid,  p.  78. 


OF  THE  HEAD  AND  NECK. 


279 


would  prefer  Wilmer’s  plan  of  cutting  below  the 
chin. 

In  a very  large  ranula,  of  so  long  continuance 
as  to  displace  the  teeth,  the  tumour  was  extirpa- 
ted at  a time  when  the  risk  of  suffocation  was 
imminent.  The  cure  was  not  completed,  on  ac- 
count of  tedious  exfoliations  from  the  jaw  bone, 
and  the  growth  of  fungi,  till  three  months  after 
the  operation.* 

When  mentioning  the  relation  of  the  parts  near 
to  the  angle  of  the  jaw,  it  was  stated  that  the  ton- 
sil lay  almost  opposite  to  the  root  of  the  alveolar 
process  of  the  second  molar  tooth — deep-seated — 
crossed  by  some  of  the  branches  of  the  carotid, 
and  pretty  near  to  the  external  carotid  artery 
itself.  As  this  is  a secreting  organ,  intended  to 
form  a fluid  to  assist  in  lubricating  the  parts  when 
swallowing  the  food,  it  is  freely  supplied  with  blood; 
but  by  this  very  mechanism  it  is  subjected  to  dis- 
ease; it  is  liable  to  inflammation;  it  swells,  and  as 
it  enlarges,  it  encroaches  on  the  passage  by  which 
the  air  is  admitted  into  the  larynx,  whereby  the 
breathing  is  obstructed,  and  the  deglutition  impair- 
ed. From  the  mechanical  effect  of  the  tumour  on 
these  functions,  we  would  wish  as  speedily  as  possi- 
ble to  procure  its  removal;  we  would  therefore,  vig- 
orously use  the  means  commonly  employed  to  obtain 
resolution,  and  where  these  failed  to  produce  the 
desired  effect,  we  would  without  temporizing, 

* Memoires  de  l’Acad.  de  Chirurg.  tom.  iii. 


280  ON  THE  SURGICAL  ANATOMY 

endeavour  to  conduct  the  disease  to  suppuration. 
The  abscess  generally  bursts  between  the  pillars 
of  the  fauces,  but  Dr.  Brown  has  informed  me, 
that  in  two  patients,  it  burst  through  the  velum 
pendulum  palati.  In  both  of  these  cases  the  sore 
formed  very  much  resembled  a venereal  ulcer, 
and  without  great  care  in  tracing  the  origin  and 
progress  of  the  disease,  would  have  been  mistaken 
for  a venereal  affection. 

I may  also  mention,  that  where  the  chief  pro- 
minence in  abscess  of  the  tonsil  is  seen,  not  be- 
tween the  pillars  of  the  fauces,  but  on  the  fore- 
part of  the  velum,  it  is  not  to  be  expected  that  the 
tumour  will  point  as  in  external  suppurations.  On 
the  contrary,  the  pus  will  continue  long  deep-seat- 
ed, and  were  the  surgeon  to  delay  making  an  open- 
ing, in  the  expectation  that  it  would  become  more 
superficial,  the  patient  before  this  event  took  place, 
would  die  from  suffocation  So  soon,  therefore,  as 
the  difficulty  of  breathing  renders  it  necessary,  an 
opening  is  to  be  made  into  the  abscess,  and  that 
even  where  the  matter  is  still  deep-seated;  but 
fluctuation,  generally  obscure  indeed,  must  be 
felt,  before  we  presume  to  thrust  an  instrument 
into  the  tumour.  If  this  point  be  not  fully  ascer- 
tained, a polypus  may  be  mistaken  for  an  abscess 
of  the  tonsil.  A case  in  which  a mistake  of  this 
kind  had  been  committed,  came  under  the  obser- 
vation of  Mr.  John  Bell,  who  has  very  properly- 
described  it  in  his  late  work  on  tumours. 


OF  THE  HEAD  AND  NECK. 


381 


When  we  have  resolved  oil  opening  an  abscess 
in  the  tonsil,  some  caution  is  required;  it  is  to  be 
remembered,  that  this  gland  naturally,  is  very 
near  to  the  carotid  artery,  and  that  by  enlarge- 
ment, it  is  brought  still  more  closely  in  connexion 
with  it.  Hence  this  vessel  may,  by  passing  the 
cutting  instrument  too  deep,  and  inclining  it  too 
much  toward  the  angle  of  the  jaw,  be  injured.  In 
this  country,  I have  been  informed,  that  a sur- 
geon in  opening  a tonsillitic  abscess,  actually  did 
plunge  the  knife  into  the  carotid.  I need  hardly 
add,  that  he  lost  his  patient  before  he  could  sup- 
press the  bleeding.  In  Portal’s  work,  a case  may 
also  be  read,  where  in  opening  an  abscess  in  the 
tonsil  with  a pharyngotome,  “u n habile  chirurgien 
de  Montpelier  eut  le  malheur  d’ouvrir  une  grosse 
artere  et  de  voir  perir  un  malade  d’une  hsemorr- 
hagee  si  violente,  qu’on  ne  put  jamais  parvenir  a 
1’arreter.” 

On  these  cases,  I would  only  remark,  that  they 
betray  rashness  and  ignorance  of  the  structure  of 
the  parts  about  the  angle  of  the  jaw;  they  prove 
most  incontrovertibly,  that  the  operators  were  de- 
ficient in  a knowledge  of  the  relations  of  the  ton- 
sil. One  who  is  familiar  with  the  parts  in  con- 
nexion with  the  tonsil,  will,  in  entering  the  knife 
into  an  abscess  here,  take  care  not  to  direct  its 
point  in  the  line  of  the  angle  of  the  jaw,  for  he  is 
well  aware  that  if  he  do  this,  he  may  injure  a 
large  artery.  He  will  push  the  instrument  into 
36 


282 


ON  THE  SURGICAL  ANATOMY 


the  front  of  the  tumour,  and  carry  it  directly 
backward,  as  if  he  intended  to  cut  off  a segment 
of  it:  if  he  follow  this  course,  and  transfix  the  ab- 
scess, the  worst  which  can  happen,  will  be  injury 
of  the  back  part  of  the  pharynx:  a trivial  accident 
when  compared  with  that  of  opening  a large  blood 
vessel. 

Where  the  collection  of  matter  is  large  before 
the  abscess  hurst,  the  patient  is  in  a more  dan- 
gerous situation  than  is  generally  imagined.  His 
breathing  is  obstructed  and  gasping,  he  feels 
much  anxiety  in  the  chest,  his  face  is  dark  and 
bloated,  his  eyes  are  painted  with  vessels  con- 
taining purple  coloured  blood,  they  are  prominent, 
and  seem  ready  to  start  from  their  sockets;  we 
cannot  be  deceived  in  regard  to  the  origin  of 
these  symptoms,  which  decidedly  shew,  that  the 
lungs  are  imperfectly  supplied  with  pure  air. 
Whenever  the  abscess  bursts,  the  mouth  and 
fauces  are  filled  by  a gush  of  matter,  every 
obstruction  to  the  free  entrance  of  the  air  is 
suddenly  removed,  the  patient  fetches  an  invo- 
luntary and  deep  inspiration,  air  and  matter 
rush  together  into  the  trachea,  and  death  from 
suffocation,  is  almost  the  inevitable  consequence. 

This  to  some,  may  have  the  appearance  of  a 
fanciful  description,  or  at  all  events,  an  over- 
charged picture;  but  its  fidelity  will  be  admitted, 
when  1 inform  them,  that  in  this  very  way,  a 
strong  active  young  man  lately  lost  his  life.  He 


OF  THE  HEAD  AND  NECK. 


283 


had  been  complaining  for  a few  days  of  a sore 
throat,  for  which  he  had  consulted  his  surgeon, 
who  had  employed  the  usual  remedies.  The  in- 
flammation terminated  in  suppuration;  the  abscess 
enlarged,  till  at  length  the  tumour  occupied  almost 
entirely  the  fauces;  yet  ten  minutes  before  his 
death,  he  was  walking  about  the  house,  restless 
indeed,  anxious,  and  gasping  for  breath.  The 
bursting  of  the  abscess  and  death  followed  each 
other  so  rapidly,  that  no  measures  could  be  taken 
to  prevent  the  latter  event. 

The  cause  of  death  was  not  conjectured  in  this 
instance,  the  body  was  examined,  and  the  trachea 
found  deluged  with  purulent  matter. 

To  prevent  a similar  accident,  it  would  be  ad- 
visable, where  the  tumour  is  large,  and  the  diffi- 
culty of  breathing  great,  to  puncture  the  abscess 
as  we  would  do  a hydrocele.  Were  the  matter 
evacuated  through  a canula,  there  would  be  no 
risk  of  its  finding  a wray  into  the  windpipe,  and  if 
the  stilet  were  made  to  project  only  a little  be- 
yond the  canula,  the  trocar  may  be  as  safely  used 
as  any  other  instrument. 

In  some  patients,  after  repeated  suppuration, 
but  in  others  without  any  obvious  cause,  the  ton- 
sils become  enlarged  and  indurated,  occasioning 
serious  inconvenience  both  in  breathing  and  swal- 
lowing. Sometimes  the  tumour  slowly  decreases 
in  size  by  occasional  detraction  of  blood,  followed 
by  the  repeated  application  of  small  blisters  just 


38  4 


ON  THE  SURGICAL  ANATOMY 


below  the  angle  of  the  jaw,  conjoined  with  the  daily 
internal  use  of  some  purgative  salt.  One  drachm 
of  the  sulphate  of  magnesia,  dissolved  in  eight  or 
ten  ounces  of  water,  will  keep  the  bowels  easy, 
which  is  all  that  is  required.  Where  the  tonsil 
still  continues  swelled,  notwithstanding  the  use  of 
these  remedies,  benefit  may  be  derived  from  pass- 
ing electric  sparks  through  the  tumour. 

Where  the  tumour,  in  place  of  decreasing  in 
size,  continues  to  enlarge,  we  must,  on  account 
of  the  effect  produced  on  respiration  and  deglu- 
tition, remove  the  diseased  substance.  It  is  not, 
however,  generally  necessary  to  extirpate  the 
whole  tonsil,  nor,  in  fact,  is  that  an  operation 
which,  even  if  required,  could  be  safely  accom- 
plished. It  is  fortunate  therefore,  that  in  the  dis- 
eased state  of  the  tonsil,  which  renders  its  remo- 
val necessary,  if  a part  of  the  tumour  be  extir- 
pated, what  remains  skins  over,  and  gives  no 
further  inconvenience. 

In  taking  away  a portion  of  the  tonsil,  differ- 
ent plans  have  been  employed.  Bertrandi  was 
in  the  habit  of  cutting  away  a portion  of  the 
gland  with  perfect  safety.  Gariot  also  prefers 
the  bistoury  or  sheathed  cystome  for  this  purpose, 
and  he  recommends  it  as  both  the  surest  and 
most  expeditious  mode  of  operating.*  We  have 
the  testimony  of  these  and  other  authors  to  prove, 
that  the  haemorrhage  is  seldom  profuse  after  the 

*liariot  des  Maladies  de  la  Bouehe,  p.  99. 


OF  THE  HEAD  AND  NECK. 


285 


excision  of  a part  of  the  tonsil.  The  bleeding 
will  generally  be  checked  by  gargling  the  throat 
with  cold  water,  or  by  touching  the  orifices  of 
the  vessels  with  a camel’s-hair  pencil,  dipped  in 
oil  of  turpentine  or  alcohol,  and  where  these  fail, 
it  may  be  certainly  counteracted  by  the  applica- 
tion of  a hot  wire.  In  using  the  latter,  we  must 
use  the  precaution  of  conveying  the  heated  wire 
along  a canula,  otherwise  it  would  be  liable  to 
come  in  contact  with  parts  which  we  would  not 
wish  it  to  touch. 

Sometimes  after  the  prominent  part  of  a dis- 
eased tonsil  has  been  cut  off,  the  wound  does  not 
heal  readily;  the  cure  is  retarded  by  a soft 
lymphatic  looking  fungus,  which  shoots  up  from 
the  surface  of  the  sore.  Before  recovery  will 
take  place,  this  excrescence  must  be  destroyed. 
This  has  been  accomplished,  by  touching  it  twice 
or  thrice  a- day  with  the  muriate  of  ammonia, 
finely  powdered;  but  on  the  whole,  the  actual 
cautery  is,  perhaps,  preferable  to  any  other 
plan. 

Some  surgeons  are  afraid  to  use  the  knife,  and 
some  patients  dread  the  pain  of  cutting;  such 
may  employ  the  double  ligature  proposed  by 
Cheselden.  A curved  needle,  armed  with  a 
double  ligature,  composed  either  of  very  flexible 
wire  or  waxed  thread,  is  to  be  passed  through 
the  tonsil,  as  near  to  its  junction  with  the  sound 
parts  as  possible,  by  which  the  swelling  is  divid- 


286 


ON  THE  SURGICAL  ANATOMY 


ed  into  two  equilateral  portions.  Then  separate 
the  threads,  and  run  the  two  belonging  to  the 
upper  segment  of  the  tumour  through  a polypus 
cariula,  next  push  the  latter  home  against  the  root 
of  the  morbid  mass,  and  retain  it  there  by  twist- 
ing the  ends  of  the  ligature  round  the  bars  of 
the  canula.  Treat  the  under  half  of  the  tumour 
precisely  in  the  same  manner,  and  tighten  the 
threads  daily,  till  the  intercepted  parts  drop  off. 
This  operation  which  seems  to  be  very  simple 
and  easily  planned,  is  nevertheless,  difficult  in 
execution;  the  tumour  on  which  we  are  to  ope- 
rate is  large;  the  cavity  in  which  we  are  to  act  is 
confined.  I would  never,  therefore,  employ  the 
ligature,  until  foiled  in  removing  the  tumour  by 
other  means,  and  until  the  patient  decidedly  ob- 
jected to  the  use  of  the  knife.* 

It  is  not  to  be  inferred  that  everv  chronic  en- 

%/ 

largement  of  the  tonsil  depends  on  thickening 
and  induration  of  the  substance  of  the  gland;  it 
is  sometimes  produced  by  the  formation  of  cal- 
culi. These  seldom  in  the  amygdalae  acquire  any 
considerable  size,  but  their  presence  is  produc- 
tive of  irritation,  and  repeated  attacks  of  cyn- 
anche;  the  inflammation  generally  proceeding  to 
suppuration.  After  each  successive  discharge  of 
matter,  a solid  and  circumscribed  tumour  remains 
in  the  situation  of  the  tonsil,  where,  sometimes 
by  a probe,  the  calculus  may  be  detected.  It  is 

* Sec  Appendix  (D.) 


OF  THE  HEAD  AND  NECK. 


287 


evident,  that  a surgeon  who  is  not  aware  that 
calculi  may  be  formed  in  this  gland,  will  be 
liable  to  consider  the  tumour  as  dependent  on 
some  more  serious  affection.  I have  never  had 
an  opportunity  of  examining  a patient  with  a cal- 
culus in  the  tonsil,  but  I have  received  the 
history  of  three  cases  of  this  disease,  all  oc- 
curring in  the  same  family,  and  known  to  Mr. 
Robert  Wilson,  an  intelligent  practitioner  in 
Beith,  who  sent  me  the  calculi. 

The  first  case  was  that  of  Agnes  Wark,  who 
soon  after  exposure  to  cold  and  wet  feet,  com- 
plained of  a fulness  about  the  fauces,  accom- 
panied with  pain,  which  extended  along  the 
Eustachian  tube  of  the  left  side.  Her  respira- 
tion was  obstructed,  and  her  deglutition  difficult. 
After  three  weeks,  the  tumour  suppurated  and 
burst  externally.  The  sore  discharged  purulent 
matter  for  a fortnight,  when  it  healed.  Two 
months  afterward,  from  a similar  cause,  the 
throat  became  again  inflamed,  suppurated,  burst, 
and  healed.  Indeed,  during  eighteen  months, 
she  had  frequent  attacks  of  cynanche  tonsillaris, 
all  of  which  uniformly  terminated  in  suppura- 
tion, and  all  of  the  abscesses  burst  externally. 

It  was  not,  however,  till  about  this  time,  that 
she  discovered  after  the  sore  had  healed,  a regu- 
lar and  solid  tumour  on  the  left  side,  which  pro- 
truded the  skin,  just  below  the  angle  of  the  jaw. 
Soon  afterward,  and  without  any  obvious  cause, 


288 


ON  THE  SURGICAL  ANATOMY 


she  had  a very  severe  and  long  continued  attack 
of  iraflammation  in  her  left  tonsil.  An  abscess 
formed  and  burst  externally,  discharging  matter 
during  a full  year,  by  eight  small  appertures. 

Before  this  time  she  had  never  consulted  any 
medical  practitioner,  but  she  was  now  induced, 
from  the  long  duration  of  the  disease,  and  the 
inconvenience  resulting  from  the  pain  and  dis- 
charge, to  shew  the  ulcerated  part  to  a surgeon, 
who  discovered  by  probing  the  sore,  that  a cal- 
culus was  lodged  in  the  tonsil.  Having  ascer- 
tained this  point,  he  next  endeavoured  by  an 
external  incision,  to  extract  the  concretion;  but 
the  bleeding  deterred  him  from  enlarging  the 
wound  to  a sufficient  extent,  so  that  his  operation 
ended  in  detaching  a fragment  from  the  body  of 
the  calculus.  Being  foiled  in  this  attempt,  he 
next  advised  the  application  of  a cataplasm  over 
the  wound,  and  directed  the  patient  to  wash 
the  throat  frequently  during  the  day  with  some 
simple  gargle.  By  this  treatment,  little  altera- 
tion was  apparently  produced;  but  in  the  course 
of  fourteen  days,  the  calculus  dropped  from  the 
tonsil  into  the  mouth.  From  this  time  the  sores 
began  to  heal,  the  discharge  lessened,  the  pain 
abated,  and  after 'the  cure,  which  was  completed 
in  a few  weeks,  she  had  no  return  of  cynanche 
during  a period  of  twelve  years. 

The  brother  of  this  woman  was  similarly  af- 
fected, but  in  him  the  disease  continued  during 


OF  THE  HEAD  AND  NECK. 


289 


twenty  years  before  the  calculus  was  discharged 
from  the  tonsil.  In  the  third  patient,  who  was 
nearly  related  to  the  two  former  ones,  the  con- 
cretion dropped  into  the  mouth,  about  two  years 
after  the  commencement  of  the  complaint  in  the 
tonsil. 

In  these  patients  considerable  inconvenience 
was  occasioned  by  the  encroachment  of  the  tonsil 
on  the  fauces,  an  inconvenience  which  was  rather 
increased  than  diminished  by  suppuration,  and 
which  was  constantly  on  the  increase.  Consider- 
ing this,  a surgeon  who  satisfied  himself  with  a 
cursory  examination  of  the  patient,  might  have 
imagined  the  enlargement  depended  on  thicken- 
ing of  the  substance  of  the  gland  itself,  and  on 
that  supposition  he  might  have  begun  an  operation, 
which  would  have  terminated  in  his  own  discom- 
fiture. 

In  the  first  case,  I would  likewise  notice  an 
impropriety  committed  by  the  surgeon,  who  be- 
lieved that  by  enlarging  the  external  sore  he 
would  have  it  in  his  power  to  extract  the  stone, 
Here  it  is  evident,  that  he  forgot  that  the  con- 
cretion was  deep-seated,  that  it  was  by  sinous 
passages  that  he  brought  the  probe  to  grate 
against  it,  and  above  all,  that  it  lay  imbedded 
amongst  large  vessels,  which  must  have  been  di- 
vided, before  a wound  could  be  made  of  sufficient 
size  to  permit  of  the  extraction  of  the  calculus. 
On  these  accounts  an  external  incision  is  eom- 
37 


290 


ON  THE  SURGICAL  ANATOMY 


pletely  out  of  the  question,  so  long  as  the  concre- 
tion continues  deep-seated;  it  is  only  allowable 
when  the  calculus  has,  by  suppuration  and  ulcera- 
tion, worked  its  way  outward,  so  that  it  is  only 
detained  by  the  skin.  Here,  any  other  than  an 
external  incision  would  be  preposterous;  but  there 
can  be  no  doubt  regarding  the  propriety  of  an 
internal  cut  into  the  substance  of  the  tonsil,  in 
order  to  extract  the  foreign  substance,  so  soon  as 
its  existence  has  been  ascertained. 

These,  and  indeed  all  tonsill itic  concretions, 
have  been  distinguished  hy  a fetid  stercoraceous 
odour. 

Sometimes  the  concretion  does  not  acquire  the 
same  degree  of  solidity  as  in  the  preceding  cases. 
In  some  patients  it  forms  in  the  crypt*  of  the 
tonsil,  enlarging  them,  and  even  projecting  into 
the  fauces.  Where  it  assumes  that  form,  it  can, 
by  any  blunt  pointed  instrument,  be  turned  out 
from  the  recesses  of  the  tonsil,  in  gritty  masses  of 
a dirty  white  colour. 

The  formation  of  this  gritty  matter,  would  seem 
to  be  connected  with  a deranged  state  of  the 
intestinal  canal.  It  will  be  necessary  to  pick  the 
foreign  substance  from  the  tonsil,  and  to  prevent 
its  reproduction,  the  bowels  must  be  restored  to 
their  natural  action.  It  is  by  no  means  an  un- 
common affection. 

So  soon  as  the  external  carotid  artery  has 
emerged  from  behind  the  stylo- hyoideus  and  the 


OF  THE  HEAD  AND  NECK, 


2&1 


digastric  muscles,  and  while  it  is  lying  over  the 
internal  carotid,  it  attaches  itself  to  the  parotid 
gland,  with  which,  for  the  remainder  of  its 
course,  it  continues  to  be  very  intimately  con- 
nected, and  in  the  substance  of  which  it  sends 
off  its  branches.  This  gland  and  its  connexions 
are  too  important  to  be  passed  over  with  a cur- 
sory notice;  its  situation  and  extent  ought  to  be 
known  to  every  student;  it  is  not  the  circumscri- 
bed and  well-defined  gland  which  many  believe 
it  to  be,  neither  is  it  confined  to  the  space  be- 
tween the  ascending  plate  of  the  lower  jaw- 
bone and  the  ear.  That  is  really  a small  part  of 
the  gland,  the  limits  of  which  cannot  be  shewn 
by  a superficial  dissection,  which  can  give  no 
just  idea  of  either  the  extent  or  connexions  of 
the  parotid  gland.  To  unfold  these,  we  must 
penetrate  deeper,  we  must  follow  the  gland  to 
the  very  root  of  the  external  auditory  sinus,  al- 
most to  the  internal  carotid  artery  and  jugular 
vein;  we  must  trace  it  sunk  behind  the  plate  of 
the  jaw  bone,  and  see  it  adhering  there  to  the 
internal  pterygoid  muscle;  we  next  follow  it  be- 
hind the  sterno-mastoid  muscle,  and  down  along 
the  neck  a little  way  below  the  angle  of  the 
jaw,  and  examine  it  where  folded  over  the  pos- 
terior edge  of  the  masseter  muscle,  and  when  we 
have  done  all  this,  we  shall  only  have  made  our- 
selves acquainted  with  the  mere  locality  of  the 
gland.  We  shall  have  still  to  learn  diat  it  is, 


292 


ON  THE  SURGICAL  ANATOM! 


while  buried  in  the  deepest  part  of  the  parotid 
gland,  that  the  external  carotid  artery  gives  off 
the  arteria  posterior  auris,  and  divides  into  the 
internal  maxillary  and  temporal  arteries,  and 
likewise  that  it  is  while  imbedded  in  this  gland 
that  the  portio  dura  crosses  the  artery. 

The  parotid  gland  is  then  sunk  so  deep,  and 
is  so  firmly  locked  in  between  the  ascending 
plate  of  the  lower  jaw  bone  and  the  mastoid  pro- 
cess, that  when  it  becomes  diseased  the  patient 
cannot  open  his  mouth,  and  from  the  effect  of  the 
fasern  the  tumour  is  flat.  Its  extirpation  is  quite 
out  of  the  question;  its  impracticability  is  pro- 
ved by  reviewing  the  connexions  of  the  gland. 
Whoever  has,  in  situ,  injected  the  salivary  duct 
with  mercury,  and  then,  even  where  the  gland 
was  healthy,  where  it  was  free  from  preternatur- 
al adhesions,  and  limited  to  its  natural  size,  has 
tried  to  cut  it  out,  would  be  convinced,  when  he 
saw  the  mercury  running  from  innumerable  pores, 
that  the  gland  extends  into  recesses  into  which 
he  could  not  trace  it  in  the  living  body.  If  this 
be  true  in  health,  what  must  it  be  in  disease, 
where  the  parts  are  wedged  between  the  angle  of 
the  jaw  and  the  mastoid  process,  and  nitched 
into  every  interstice  around.  On  the  dead  sub- 
ject I have  attempted  the  extirpation  of  such  tu- 
mours, but  even  there  have  never  succeeded  in 
clearing  away  fully  the  diseased  substance. 


OF  THE  HEAD  AND  NECK. 


293 


The  inference  from  this  fact  is  too  plain  to  re- 
quire to  be  expressed.  Those  who  assert  that 
they  have  extirpated  the  parotid  gland,  have,  I 
am  fully  convinced,  mistaken  that  little  conglo- 
bate gland  which  lies  imbedded  in  its  substance, 
and  which  does  sometimes  enlarge,  producing  a 
tumour  in  many  respects  resembling  a diseased 
parotid,  for  the  parotid  itself.  I have  seen  an 
enlargement  of  the  lymphatic  glands  taken  for  a 
diseased  parotid,  and  the  same  has  occurred  to 
Mr.  Cruickshank.  This  author,  when  speaking 
of  the  absorbents  and  glands  about  the  parotid, 
adds,  that  he  had  known  these  “indurated  and 
enlarged  to  the  size  of  a hen’s  egg,  which  gave 
suspicion  of  a cancerous  affection  in  the  parotid 
itself.”* 

This  gland,  in  the  early  stage  of  the  complaint, 
may  be  extirpated,  but  the  parotid  cannot. 
“The  cutting  out  completely  the  parotid  gland 
is  a thing  quite  impossible,  since  the  greatest  of 
all  the  arteries,  viz.  the  temporal  and  the  maxil- 
lary, lie  absolutely  imbedded  in  the  gland. ”f 

If  we  may  credit  the  assertion  of  Mr.  Charles 
Bell,  we  must  believe  that  his  brother,  assisted 
by  himself,  actually  accomplished  this  impossi- 
bility: “I  assisted  my  brother  formerly  in  this 
operation.  The  whole  gland  was  diseased;  it 

* Cruickshank’s  Anatomy  of  Absorbent  "Vessels,  second  edition,  page 
‘203. 

t Bell’s  Anatomy,  vol.  2d,  page  293, 


294 


ON  THE  SURGICAL  ANATOMY 


was  dissected  all  round,  until  it  remained  attach- 
ed only  at  that  deep  point  which  is  behind  the 
angle  of  the  jaw,  where  it  encircles  the  artery. 
A ligature  was  put  upon  its  root,  and  in  a few 
days  it  dropt  off,  more  completely  eradicated 
than  could  have  been  possible  with  the  knife.”* 
Nor  does  this  assertion  of  Mr.  Charles  Bell’s 
rest  on  his  authority  alone.  Mr.  John  Bell  avows 
the  operation  which  he  would  wish  to  make  us 
believe  he  had  often  performed,  “for  I had  of- 
ten extirpated  the  diseased  parotid.”!  With  his 
own  words  he  shall  condemn  himself:  “What 
shall  we  think,  then,  of  those  surgeons  who  talk 
in  such  familiar  terms  of  cutting  out  the  parotid 
gland.”! 

Did  Mr.  Bell  know  the  connexions  of  this 
gland  less  perfectly  when  he  wrote  his  System  of 
Anatomy  than  afterward?  Did  this  lately  ac- 
quired knowledge  teach  him  that  his  former  in- 
ference was  incorrect?  Did  it  convince  him  that 
the  parotid  gland  may  really  be  extirpated? 
Did  he  from  this  belief  actually  undertake  and 
accomplish  its  excision  with  the  assistance  of  his 
brother?  Let  Mr.  C.  Bell  determine  the  motives 
which  induced  him  to  “talk  in  such  familiar  terms 
of  cutting  out  the  parotid  gland;”  and  let  Mr. 
John  Bell  assign  some  more  satisfactory  reason  for 

* Bell’s  Dissections,  third  edition,  p.  249. 

tBell  on  Tumours,  p.  210. 

i Bell’s  Anatomy,  vol.  2d,  p.  293. 


OP  THE  HEAD  AND  NECK.  l295 

declining  the  extirpation  of  this  gland  than  its 
connexions  with  the  temporal  and  maxillary  arte- 
ries, for  these  might  both  be  controlled.  The 
arteries  are  not  our  dread;  they  do  not  deter  us 
from  performing  this  operation;  but  the  nitching  of 
the  gland  into  interstices  from  which  we  cannot 
extricate  it,  leave  us  no  hope  of  clearing  away  all 
the  diseased  substance,  without  which  any  opera- 
tion would  prove  abortive.  This  is  our  chief  con- 
sideration, and  this  insurmountable  obstacle,  our 
only  objection. 

I have  endeavoured  to  place  the  question  re- 
garding the  extirpation  of  the  parotid  gland  in  its 
proper  light,  and  to  shew  from  the  anatomy  of 
its  connexions,  that  it  is  an  operation,  which, 
in  no  situation,  and  under  no  circumstances, 
ought  to  be  undertaken.  If  the  disease  be  really 
seated  in  the  parotid  itself,  which,  in  nine  cases 
out  of  ten,  it  will  not  be,  we  could  have  no  expec- 
tation of  extirpating  every  particle  of  the  tainted 
substance.  This  must  decide  the  question.  But 
how  are  the  operations  to  be  explained,  in  which 
this  gland  was  reported  to  have  been  cut  out? 
This  will  not  be  a difficult  task.  The  descrip- 
tions of  the  operations  prove,  I think,  that  it  was 
not  the  parotid  itself  which  was  removed,  but  a dis- 
eased conglobate  gland,  of  which  there  are  usual- 
ly two  connected  with  the  parotid.  One  is  gen- 
erally placed  beneath  that  lobe  of  the  parotid 
which  extends  lower  than  the  angle  of  the  jaw;  the 


296  ON  THE  SURGICAL  ANATOMY 

other  is  imbedded  in  the  very  centre  of  the  paro- 
tid, lying  commonly  opposite  to  the  division  of 
the  external  carotid  artery  into  the  temporal  and 
maxillary  branches. 

The  first  is  not  very  deep-seated,  it  is  merely 
covered  by  the  cervical  fascia  and  the  thin  de- 
pendent lobe  of  the  parotid  gland.  When  it 
swells,  it  forms  a tumour  just  below  the  angle  of 
the  jaw,  and  rather  behind  it;  not  fully  circum- 
scribed, not  even  in  the  incipient  stage  freely 
moveable;  still  where  it  is  not  very  large,  it  may 
be  easily  enough  extirpated.  Anterior  to  it  there 
is  no  part  of  consequence;  behind  it  the  trunk  of 
the  external  carotid  artery  is  placed;  yet,  by  the 
fingers,  the  tumour  may  be  safely  detached  from 
that  vessel.  This  was  the  species  of  tumour  ex- 
tirpated by  Mr.  John  Bell  from  about  the  angle 
of  the  jaw  of  the  late  Mr.  William  Dunlop.* 
These  remarks  on  tumours  formed  at  the  angle 
of  the  jaw,  will  be  well  illustrated  by  the  follow- 
ing case,  which  was  under  the  care  of  Mr.  Ander- 
son, with  whom  I saw  the  patient,  f 

In  this  patient  there  were  three  tumours  about 
the  angle  of  the  jaw,  one  of  which  at  least,  had 
existed  during  seven  years.  The  largest  tumour, 
which  was  about  the  size  of  a pullet's  egg,  was 

* Bell  on  Tumours,  vol.  ii.  p.  216. 

t The  Tacts  which  I have  mentioned  in  this  case,  were  deri\ed  from  dif- 
ferent letters  which  passed  between  the  patient  and  tue  medics  " utle  nen 
to  whom  he  submitted  his  case.  These  letters  I saw  and  read  at  the  time 
the  operation  was  performed. 


OF  THE  HEAD  AND  NECK. 


297 


seated  between  the  mastoid  process  and  the 
ascending  plate  of  the  jaw  bone.  It  was  pro- 
minent, and  in  part  moveable;  it  was  as  move- 
able as  could  be  expected,  since  it  was  covered 
by  a fascia.  It  could  be  moved  from  side  to 
side,  but  it  could  neither  be  fully  grasped  by  the 
fingers,  nor  its  extent  fairly  defined;  its  depth, 
especially  could  not  be  determined.  It  might  dip 
backward,  but  there  was  no  proof  that  it  did  so; 
nay,  from  its  being  moveable,  there  was  rea- 
son to  suppose  that  it  did  not.  The  tumour  next 
in  point  of  size  lay  just  below  the  angle  of  the 
jaw;  was  rather  less  than  a walnut,  and  rolled 
freely  under  the  skin  and  fascia,  and  the  fingers 
could  be  made  nearly  to  encircle  it.  When  pulled 
forward,  the  large  vessels  could  be  distinguished 
behind,  completely  unconnected  with  the  tumour. 
The  third  and  smallest  tumour  was  placed  by  the 
side  of  the  last,  and  both  lay  nearly  over  the  di- 
grastic  muscle. 

From  first  perceiving  these  tumours,  they  had 
steadily  increased,  although  slowly;  or  if  at  any 
period  they  had  been  stationary,  it  was  after  an 
incision  had  been  made  into  the  uppermost:  their 
consequences  were,  therefore,  to  be  dreaded, 
which  made  the  patient  naturally  enough  anxious 
to  have  them  removed.  With  a view  to  this,  he 
consulted  several  practitioners  of  the  highest 
professional  talents,  both  in  London  and  Edin- 
burgh. 


38 


298 


ON  THE  SURGICAL  ANATOMY 


Mr.  John  Bell,  who  was  first  applied  to,  was 
decided  in  his  opinion,  that  the  tumours  were 
formed  by  dilated  veins,  but  the  veins  were  not 
simply  varicose;  there  was  something  strange 
and  undefined  in  his  notions.  He  talked  about  the 
dilated  veins  being  inclosed  in  a bag;  and  so  fully 
was  he  impressed  with  the  truth  of  this  conjec- 
ture, that  he  actually  made  an  incision  into  the 
largest  tumour;  blood  only  followed  the  knife,  yet 
both  the  surgeon  and  his  patient  flattered  them- 
selves, that  this  cut  would  effectually  resist  the 
progress  of  the  disease.  Mr.  Bell  predicted, 
that  by  the  inflammation  consequent  to  this- ope- 
ration, the  sides  of  the  cyst  containing  the  veins 
would  become  so  thickened,  that  if  it  did  continue 
to  enlarge,  the  increase  would  be  extremely  slow. 
For  a time  the  patient  believed  this.  Soon,  how- 
ever. he  was  convinced  that  his  hopes  were  ill- 
founded;  again,  therefore,  he  had  recourse  to  Mr. 
Bell,  who  still  persisted,  that  the  nature  of  the 
disease  was  the  same  as  formerly;  and  again  he 
repeated  his  opinion  that  the  sac  would  not  en- 
large with  rapidity.  Nevertheless,  the  swellings 
augmented,  the  patient  became  more  and  more 
anxious,  for  he  began  to  lose  confidence  in  Air. 
Bell’s  prediction.  He  still  believed  that  the 
tumours  were  produced  by  dilated  veins;  but  now 
not  even  the  boldness  of  Mr.  Bell’s  tone  could 
persuade  him  that  they  would  not  some  time  or 
other  endanger  his  life. 


OF  THE  HEAD  AND  NECK. 


299 


Impressed  with  this  belief,  he  submitted  his 
case  to  three  of  the  most  eminent  surgeons  in 
London,  all  of  whom  coincided  in  opinion  that 
the  tumours  were  glandular;  but  regarding  the 
nature  of  the  complaint,  there  was  a difference  of 
opinion.  One  practitioner  supposed  the  swell- 
ings to  depend  upon  derangement  of  the  biliary 
system;  another  thought  that  they  might  arise 
from  the  torpidity  of  the  absorbent  system;  one 
turned  his  attention  to  the  state  of  the  bowels; 
while  the  other  prescribed  such  medicines  as  are 
supposed  to  increase  the  activity  of  the  lympha- 
tics. All  the  three  practitioners  dissuaded  the 
patient  from  submitting  immediately  to  an  opera- 
tion; but  one  of  them  encouraged  him  to  hope, 
that  when  the  swellings  had  become  larger  and 
more  prominent,  they  might  be  extirpated.  He 
followed  the  prescriptions  given  him,  but  found 
that  the  growth  of  the  tumours  was  uncontrolled. 
Disappointed  in  his  expectations,  and  rendered 
solicitous  about  his  safety,  he  was  desirous  of 
having  the  diseased  parts  removed  by  operation. 

Mr.  Anderson  saw  him,  and  gave  him  hopes 
that  it  was  not  yet  too  late  to  operate;  but  re- 
quested, at  the  same  time,  the  advice  of  some 
other  surgeons.  Several  were  consulted;  and 
the  general  voice  was  against  operation.  The 
patient,  who  was  a most  intelligent  gentleman, 
was  faithfully  informed  respecting  what  had 
passed.  He  was  explicitly  told,  an  operation 


300 


ON  THE  SURGICAL  ANATOMY 


might  prove  unsuccessful,  since,  perhaps,  it  would 
be  found  impracticable  to  clear  away  all  the  dis- 
eased substance;  the  smallest  portion  of  which 
being  allowed  to  remain,  he  was  taught  to  be- 
lieve, would  prevent  the  wound  from  healing. 
This  was  the  only  risk,  there  was  no  immediate 
hazard,  because  it  was  in  the  power  of  the  sur- 
geon to  stop  short  at  the  point  where  actual  dan- 
ger began.  The  uncertainty,  therefore,  of  the 
issue  of  the  operation  was  what  the  patient  had 
to  consider,  and  to  balance.  He  was  apprised, 
that  from  the  previous  history  of  the  tumours, 
there  could  be  little  doubt,  that  they  would  still 
continue  to  enlarge;  their  nature  was  also  such, 
that  there  was  reason  to  fear  that  ulceration 
would  ultimately  take  place,  fungus  be  formed, 
hectic  induced,  and  death  follow.  On  these 
facts  the  patient  reflected,  and  his  decision  was, 
that  an  operation  should  be  performed. 

In  an  hour  he  was  prepared.  With  firmness 
he  seated  himself  on  a chair,  then  reclined  his 
head  on  the  breast  of  an  assistant,  and  with  for- 
titude and  an  unmoved  countenance,  bore  a pro- 
tracted and  painful  operation.  An  incision  was 
made  by  Mr.  Anderson  from  the  root  of  the 
ear  to  below  the  angle  of  the  jaw.  It  was  of 
such  a length  as  to  expose  fully  the  whole  ex- 
tent of  the  tumours.  The  smallest  tumours 
were  readily,  after  the  division  of  the  fascia,  de- 
tached merely  by  the  fingers,  and  when  brought 


OF  THE  HEAD  AND  NECK. 


301 


away,  the  diseased  substance  was  found  included 
in  a firm  membranous  capsule.  The  removal 
of  the  uppermost  tumour  was  rather  more  diffi- 
cult, owing  to  its  connexion  with  the  parotid 
gland.  It  had  originally  been  formed  by  en- 
largement of  one  of  the  small  glands,  which  are 
covered  by  the  depending  lobe  of  the  parotid. 
As  the  tumour  increased,  it  pushed  this  lobe  up- 
ward and  outward,  and  this  was  the  only  cause  of 
difficulty.  So  soon  as  this  lobe  of  the  parotid  was 
turned  aside,  the  diseased  gland  was,  with  the 
slightest  effort,  started  from  its  bed  or  cup,  in- 
vested with  its  sheath. 

After  the  first  incision,  all  the  other  parts  of 
the  operation  were  executed  by  the  fingers;  and 
as  each  of  the  tumours  were,  after  their  removal, 
found  to  have  their  capsules  entire,  there  could 
not  possibly  be  any  of  the  diseased  substance 
left  behind.  Two  little  arteries  which  had  been 
divided,  were  now  secured,  and  the  margins  of 
the  wound  brought  together  and  retained  in  con- 
tact. In  a few  weeks,  the  wound  was  completely 
healed. 

Plate  VI.  will  illustrate  the  deep-seated  con- 
nexions of  a tumour,  nitched  in  between  the 
parotid  gland  and  the  digastric  and  stylo-hyoideii 
muscles.  The  latter  only  are  interposed  between 
the  swelling  and  the  external  carotid  artery. 
Above  and  below  the  line  of  these  muscles,  the 
tumour  is  absolutely  in  contact  with  that  vessel. 


302 


ON  THE  SURGICAL  ANATOMY 


On  this  account,  a tumour  which  had  formed  be- 
hind the  angle  of  the  jaw  in  the  woman  Mander- 
son,  had  a vigorous  pulsatory  motion,  insomuch, 
that  one  would  without  care,  have  been  induced  to 
believe  the  carotid  artery  to  be  aneurismal.  In  this 
woman,  the  swelled  gland  does  not  simply  lie  over 
the  carotid  artery,  it  turns  round  its  tracheal 
side,  insinuating  itself  between  the  vessel  and  the 
posterior  margin  of  the  hyo-glossus  muscle,  so  that 
by  pressing  aside  the  ligament  running  from  the 
pterygoid  muscle  to  the  side  of  the  neck,  it 
touched  the  pharynx.  This  I was  rendered  cer- 
tain of,  by  introducing  a finger  deep  along  the 
mouth,  and  examining  the  pharynx,  where  the 
tumour  can  be  distinctly  felt  adhering  to  its  side, 
and  establishing  connexions  which  completely 
forbade  any  operation. 

Disease  of  the  lower  lobe  of  the  parotid  gland 
is  not  to  be  mistaken  for  enlargement  of  the  con- 
globate gland,  which  it  covers.  Sometimes  this 
lobe  of  the  parotid  gland  becomes  sacculated, 
forming  a collection  of  watery  viscid  fluid.  Such 
a tumour  begins  just  behind  the  angle  of  the  jaw, 
and  from  that  nucleus,  proceeds  downward  and 
laterally.  As  the  swelling  is  covered  by  the 
fascia,  it  is  consequently  tense;  and  although  the 
sides  of  the  cyst  be  thin  and  pliant,  fluctuation 
is  obscure.  Yet  although  ill-defined,  it  may 
generally,  by  care,  be  detected.  This  species  of 
tumour  does  not  require  to  be  extirpated,  its  na- 


OF  THE  HEAD  AND  NECK. 


303 


ture,  so  long  as  it  is  sacculated,  is  simple;  it  is  a 
mere  body  of  saliva,  hollowed  out  in  the  glandular 
substance.  In  the  incipient  stage,  therefore,  the 
tumour  is  to  he  opened,  its  gelatinous  contents 
evacuated,  and  the  inner  surface  of  the  hag  irrita- 
ted by  passing  a seton  through  it,  or  by  stimulat- 
ing injections. 

Just  below,  and  behind  the  angle  of  the  jaw,  I 
have  mentioned,  that  a sacculated  tumour  is 
sometimes  formed  by  the  lobe  of  the  parotid 
gland.  At  other  times,  the  internal  jugular  vein 
is  dilated  at  the  same  place,  into  a considerable 
sized  pouch.  I have  a cast  which  I received  from 
my  friend  Dr.  Monro,  which  very  finely  illus- 
trates the  position  and  external  characters  of  a 
tumour  of  this  nature.  No  operation  can  be  per- 
formed here;  the  surgeon  must,  therefore,  be 
careful,  not  to  confound  a dilatation  of  the  jugular 
vein  with  a sacculated  parotid  tumour.  In  the 
latter,  we  cannot  by  pressure  disperse  the  swell- 
ing; in  the  former,  the  tumour  can  be  completely 
emptied  by  squeezing  it  between  the  fingers. 
There  cannot,  therefore,  be  any  apology  for  a 
surgeon  who  mistakes  the  one  for  the  other. 

In  planning  the  removal  of  a tumour  from  be- 
hind the  angle  of  the  jaw,  the  situation  of  the  lobe 
of  the  parotid  is  to  be  kept  in  remembrance,  be- 
cause this  connexion,  will,  in  some  measure,  regu- 
late the  surgeon;  it  will  direct  the  form  of  his 
incision.  His  object  must  be  to  avoid  injury  of 


304  ON  THE  SURGICAL  ANATOMY 


the  glandular  substance,  not  from  any  idea  that 
a wound  of  it  would  affect  the  ultimate  success  of 
the  operation,  but  because  it  would  probably 
retard  the  cure.  A salivary  fistula  would  be  the 
consequence,  unless  steady  compression  was  ap- 
plied and  persisted  in  for  some  time  after  the 
removal  of  the  tumour.  This  it  would  be  desira- 
ble to  avoid. 

Such  a tumour  will,  with  the  greatest  prospect 
of  avoiding  the  formation  of  a salivary  fistula,  be 
removed,  by  making  a triangular  flap  of  the  skin 
over  it,  directing  the  apex  towards  the  clavical. 
The  knife  is  not  in  the  first  instance,  to  penetrate 
deeper  than  the  fascia,  from  which  the  integu- 
ments are  to  be  turned  up.  Next  the  fascia  is 
to  be  divided  by  a similarly  shaped  incision,  after 
which,  the  lobe  of  the  parotid  gland  and  the  fas- 
cia are  to  be  raised  from  over  the  tumour,  and 
held  back  by  an  assistant  during  the  time  occu- 
pied by  the  surgeon,  in  detaching  with  the  fingers 
the  swelled  gland  from  its  adhesions  behind.* 
If  the  fingers  be  alone  employed  for  this  purpose, 
there  will  be  no  danger  of  injuring  any  vessel, 
but  where  the  scalpel  has  been  used,  the  poste- 
rior facial  vein  has  been  cut.  This,  although  a 
trifling  accident,  may  be  easily  avoided. 

* Mr.  Walker,  after  having  insulated  the  tumour,  “finding  its  roots  to 
run  very  deep,  and  the  artery  pulsating  strongly,  the  tumour  being  in 
actual  contact  with  the  external  carotid  he  put  a ligature  round  the  root 
of  the  gland,  which  came  away  on  the  following  day.”* 

* Bell’s  System  of  Dissections,  3d  edit.  p.  249. 


OF  THE  HEAD  AND  NECK. 


305 


When  the  tumour  is  removed,  the  parts  which 
have  been  raised  are  to  be  laid  back,  and  retained 
in  their  place  by  a compress,  supported  by  a twist- 
ed roller.  Sutures  will  not,  in  any  instance,  be  re- 
quired to  keep  the  edge  of  the  wound,  together, 
but  strips. of  adhesive  plaster  may  be  used. 

Sometimes  spontaneously,  sometimes  from  blows 
about  the  angle  of  the  jaw,  but  oftener  from  ab- 
sorption of  irritating  matter  from  the  gums,  the 
antrum,  or  the  recess  of  the  nose,  the  little  gland 
in  the  centre  of  the  parotid  swells.  As  the  gland 
lies  deep,  the  tumour  formed  by  it,  is  for  a length 
of  time,  very  ill-defined.  Between  the  jaw  and  the 
mastoid  process,  we  discover  by  examination, 
rather  a fullness  than  a regular  swelling,  and  the 
patient  complains  of  tension  and  stiffness  in  the 
region  of  the  parotid. 

During  the  enlargement  of  this  gland,  it  pres- 
ses on  the  parotid,  producing  absorption  of  its 
substance,  by  which  the  tumour  comes  ultimately 
to  take  the  place  of  the  parotid:  it  is  in  the  end, 
equally  nitched  in  among  the  parts  at  the  angle 
of  the  jaw,  and  its  extirpation  is  equally  imprac- 
ticable. Unless,  therefore,  we  resolve  in  the  very 
early  stage  of  the  disease,  to  cut  out  the  tumour, 
we  shall  never  afterward  have  it  in  our  power  to 
accomplish  that  operation;  nor  even  in  the  inci- 
pient period,  can  the  swelling  be  taken  away 
without  some  difficulty  and  danger.  It  is  this 
difficulty,  arising  from  the  confined  bed  of  the 
39 


30 G ON  THE  SURGICAL  ANATOMY 

tumour,  and  its  occupying  the  place  of  the  parotid 
gland,  which  has  led  the  few  who  have  removed 
it,  to  imagine  that  they  had  extirpated  the  paro- 
tid itself. 

In  cutting  out  this  conglobate  gland,  the  sub- 
stance of  the  parotid  is  always  considerably 
wounded,  an  incision  having  to  be  made  through 
that  portion  of  the  parotid  which  covers  the 
swelled  gland,  before  the  tumour  itself  can  be 
reached.  There  is,  therefore,  in  removing  this 
gland,  not  only  the  immediate  risk  arising  from 
its  connexions,  but  likewise  the  secondary  danger 
dependent  on  the  formation  of  a salivary  fistula. 
The  first,  where  the  tumour  is  small,  will  gene- 
rally be  overcome;  for  at  that  stage  the  diseased 
gland  still  continues  to  be  defined  by  its  capsule, 
which  does  not  adhere  very  firmly  to  the  morbid 
parts.  Where  the  tumour  is  not  bigger  than  a 
large  nut,  it  may  generally,  by  opening  its  sheath, 
be  started  from  its  cup.  The  formation  of  a sali- 
vary fistula  will  only  be  prevented,  by  maintaining 
for  a considerable  time  after  the  operation,  a firm 
and  steady  pressure  on  the  wounded  part  of  the 
parotid  gland. 

The  excision  of  this  gland  can  only  be  pru- 
dently undertaken  where  the  tumour  is  still 
small.  If  large,  the  distinction  of  its  sheath  will 
be  lost,  by  the  extension  of  the  disease  to  the 
neighbouring  parts.  This  is,  however,  from  the 
greater  resistance,  a slower  process  than  where 


OF  THE  HEAD  AND  NECK. 


307 


the  tumour  is  seated  lower  in  the  neck.  When 
the  conglobate  gland  in  the  parotid  swells,  the 
tumour  is  prevented  for  some  time  from  dipping 
deep,  by  the  resistance  afforded  by  the  pterygoid 
muscles;  and  by  the  ligament  of  the  angle  of  the 
jaw  it  is  hindered  from  encroaching  on  either 
the  larynx  or  pharynx.  Ultimately,  however, 
these  barriers  are  broken  up.  Then  the  tumour 
spreads  in  every  direction. 

I have  twice  examined  the  bodies  of  patients 
who  had  died  from  fungus  hsematodes  of  this 
gland.  In  the  last  instance,  the  ravages  of  the 
disease  were  most  extensive,  and  the  deformity 
produced,  most  hideous.  The  tumour,  which 
began  between  the  angle  of  the  jaw  and  the  mas- 
toid process,  had  enlarged  in  the  course  of  two 
years,  to  the  size  of  a boy’s  head.  It  extended 
from  just  beneath  the  orbit  on  the  left  side,  down 
to  the  clavicle,  covering  in  its  course,  the  side 
of  both  the  upper  and  lower  jaws,  distorting  the 
mouth  and  twisting  the  nose,  and  forcing  back- 
ward the  external  ear.  The  surface  of  the  tu- 
mour externally,  was  very  unequal,  but  the  in- 
teguments, although  discoloured,  were  not  ulcer- 
ated. Where,  however,  it  projected  into  the 
mouth,  it  had  formed  a fungus  which  had  dis- 
placed all  the  teeth,  and  which,  during  life,  had 
discharged  a great  quantity  of  abominably  fetid 
ichor,  intermixed  with  fragments  of  both  jaws* 


308 


ON  THE  SURGICAL  ANATOMY 


The  small  gland,  the  parotid  gland,  and  all  the 
parts  in  the  vicinity,  were  blended  together  into 
an  unseemly,  fetid,  morbid  mass,  the  greatest 
bulk  of  which  had  the  decided  character  of  fun- 
gus hsematodes.  In  the  centre  of  the  tumour, 
we  found  a large  insulated  irregular  piece  of  new 
formed  bone  lodged. 

Before  quitting  the  angle  of  the  jaw,  the  con- 
nexions of  the  portio  dura  must  be  attended  to. 
This  nerve,  when  passing  from  the  foramen  stvlo- 
mastoideum  lies  behind  the  parotid  gland,  but  it 
almost  immediately  dips  into  its  substance  It 
continues  a single  and  undivided  trunk  for  about 
half  an  inch  of  its  course.  This  part  of  the  nerve 
runs  in  a slanting  direction  downward  and  for- 
ward, imbeded  in  the  gland.  Where  the  portio 
dura  is  escaping  from  the  skull,  it  is  deep-seated, 
and  nearly  in  contact  with  the  arteria  posterior 
auris,  and  where  that  artery  and  the  occipital 
arise  by  a common  trunk,  the  latter  vessel  is  also 
quite  in  the  vicinity  of  the  portio  dura.  By  the 
styloid  process,  the  nerve  is  separated  from  the 
internal  carotid  artery  and  jugular  vein.  About 
midway  between  the  ascending  plate  of  the  jaw 
hone,  and  the  mastoid  process,  the  portio  dura 
is  nearly  opposite  to  the  posterior  facial  vein, 
and  the  external  carotid  artery. 

It  is  at  this  point,  at  a place  where  the  nerve 
is  still  deeply  covered  by  the  glandular  substance, 
that  it  divides  into  its  branches,  which  separately 


. / The  portio Diuti , crossed  at  the  wot  or' the  c IListoid  proee/s  In  Ji  the.  Irtena  posterior  aurfs.  atnl  /17 'tie  m the  ' 
fore  pait  of  C the  Sfvtozd proce/e,  and  T the  Tvtenuil  Ciirvtid*.irter\:£  the  Zhoastne  m uscle.  F the  Interna!  dnoumr  | 
Jem.  C the  Internal  Guvtul  21 the  lingual  *.4rtetp'  exposed  In"  the  mtunrxl  of  the  Jdyc-GIo/sus  mus.Je . I (he 

Lino  uni  Jlerve  sendi/w  off  A'  the  ramus  descenders  now  . I*  <_  I emts  7 at/us  and  .lithe  S/tinal  ^/eee/seriu  I ene 
entering  .1^  the  S ter  no  mastoid  muscle  . O the  horn  of'  the  /f\ofd  hone. 

’ 


OF  THE  HEAD  AND  NECK. 


309 


perforate  the  gland,  to  reach  the  cheek  and  the 
other  parts  on  which  they  are  to  be  distributed. 
Some  of  these  branches  pass  upward,  some  for- 
ward, and  others  downward.  The  largest  of 
these  branches  inclines  upward  and  forward,  and 
while  still  imbedded  in  the  gland,  it  subdivides 
into  a numerous  set  of  twigs,  which  cover,  as 
with  a net-work,  the  zygoma  and  the  arteria 
transversalis  faciei.  The  largest  of  these  twigs, 
runs  nearly  midway  between  the  zygoma,  and 
the  parotid  duct.  The  other  divisions  of  this 
nerve  ramify  over  the  face,  and  about  the  side 
of  the  throat. 

PLA  TE  VI— This  view  was  taken  from,  a full  grown 
male  subject.  The  arteries  were  injected  with  wax,  pre- 
vious to  dissection.  A is  placed  on  the  trunk  of  the 
portio  dura,  which  has  been  carefully  dissected  out  of 
the  substance  of  the  parotid  gland.  The  branches  and 
twigs  of  the  nerve,  were  more  minutely  traced  than  ha9 
been  represented.  I wished  merely  to  shew  the  great 
divisions  of  the  portio  dura;  those  which  require  to  be  re- 
membered when  studying  tic  douloureux.  This  plate  will 
likewise  be  useful  in  illustrating  the  deep-seated  connex- 
ion of  tumours  formed  about  the  angle  of  the  jaw.  The 
large  vessels,  and  the  stylo-hyoideus  and  digastricus  mus- 
cles are  fully  exposed  by  the  removal  of  the  parotid  and 
conglobate  glands. 


This  view  of  the  connexions  of  the  portio 
dura  will  shew,  that  the  trunk  of  that  nerve  can 


316  ON  THE  SURGICAL  ANATOMY 

only  be  reached  with  safety  by  an  incision  made 
along  the  anterior  edge  of  the  mastoid  process; 
at  a part  where  the  nerve  is  unquestionably  deep- 
er seated  than  it  is  further  forward;  but  where  it 
is,  at  the  same  time,  less  connected  with  important 
parts.  By  an  incision  beginning  at  the  very  root 
of  the  mastoid  process,  and  continued  downward 
and  forward,  along  the  anterior  margin  of  the 
sterno-mastoid  muscle,  the  portio  dura  may  be 
reached.  The  dissection,  no  doubt,  will  require 
to  be  deep,  but  in  performing  it,  the  surgeon 
will  not  experience  much  difficulty.  The  lobe  of 
the  ear  will  require  to  be  pulled  upward,  and 
held  forward,  while  prosecuting  this  dissection. 
In  performing  this  dissection,  the  nervus  superfi- 
cialis  coli  will  necessarily  be  divided,  where  en- 
tering the  lower  angle  of  the  parotid;  the  glan- 
dular substance  itself  will  be  injured,  and  the 
arteria  posterior  auris  will  be  cut  across.  But 
these  are  the  only  parts  which  will  require  to  be 
intermeddled  with,  in  order  to  reach  the  nerve 
at  its  very  exit  from  the  stylo- mastoid  foramen. 

Where  the  disease  is  seated  in  the  portio 
dura,  it  is  hardly  to  be  supposed  that  division 
of  one  or  more  of  the  branches  of  that  nerve, 
will  radically  remove  the  complaint.  Those  who 
remember  the  deep  situation  of  the  nerve,  where 
it  divides  into  its  branches,  and  the  way  in  which 
these  perforate  the  gland  to  reach  the  face,  will 
be  convinced,  that  an  operation  performed  on 


OF  THE  HEAD  AND  NECK. 


311 


it  after  passing  the  parotid  gland,  cannot  suc- 
ceed; enough  may  be  done  to  suspend  the  mor- 
bid action  in  the  body  of  the  nerve,  for  a short 
time,  but  generally  the  disease  will  recur.  This 
is  one  cause  of  failure,  but  there  is  yet  another, 
for  the  complaint  does  recur,  even  where  the 
trunk  of  the  affected  nerve  has  been  divided, 
provided  it  has  been  simply  divided.  Some- 
times the  pain  returns  within  a few  hours  after 
the  operation,  which  had  led  to  a belief  that 
the  nerve  had  not  been  fully  divided.  The 
sensation  at  the  instant  of  cutting  the  nerve, 
is  so  peculiar  that  no  surgeon  can  be  deceiv- 
ed; the  reproduction  of  the  pain,  depends  on 
the  manner  in  which  the  operation  has  been 
performed,  not  on  the  incomplete  division  of  the 
nerve. 

To  insure  success,  a portion  of  the  trunk  of 
the  nerve  must  be  cut  out.  So  much  of  it  must 
be  removed  as  will  prevent  reunion  of  the  divided 
extremities.  This  ought  to  be  a fixed  principle, 
because  on  this  the  permanency  of  the  cure  will, 
in  a great  measure,  depend:  I would,  perhaps, 
not  be  far  wrong  were  I to  say,  that  it  entirely 
depended  on  the  prevention  of  the  reunion  of  the 
cut  ends  of  the  nerve.  The  facts  with  which  we 
are  acquainted  would  lead  us  to  suppose,  that 
anastomosis  of  the  nerves  is  not  of  the  same  value 
to  the  nervous  system,  nor  productive  of  any  of 


312 


ON  THE  SURGICAL  ANATOMY 


those  striking  effects,  which  arise  from  vascular 
inosculation.* 

* Dr.  Haighton  has  performed  a series  of  experiments  which  throw 
considerable  light  on  the  consequences  arising  from  division  of  nerves. 
The  experiments  made  by  this  geDtleman,  and  related  in  the  85th  vol.  of 
the  Philosophical  Transactions,  go  to  prove,  that  it  is  by  reunion  or  re- 
production of  lost  substance,  that  divided  nerves  regain  their  functions. 
This  position  has  been  fully  established  by  observations  made  on  the  nervi 
vagi  of  dogs.  In  eight  hours  after  the  division  of  both  of  these  nerves, 
the  animal  died.  In  another  dog,  “1  divided  only  one  of  the  nerves  of  the 
eighth  pair.  1 was  surprised  to  see  how  slightly  he  was  affected  by  it;  for 
excepting  a little  uneasiness,  there  was  scarcely  any  alteration  perceptible, 
so  that  in  a few  hours  after  the  operation  he  took  food  as  usual.  On  the 
third  day  I divided  the  other  nerve,  but  the  same  symptoms  immediately 
supervened  here,  as  followed  the  division  of  both  nerves,  in  the  former 
experiments:  he  continued  in  a state  of  restlessness  and  anxiety,  with  pal- 
pitations and  tremors,  until  the  fourth  day,  when  he  died.  In  anothei 
dog,  in  whom  nine  days  were  allowed  to  intervene  between  the  division 
of  the  nerves,  the  animal  survived  the  second  operation  thirteen  dry?, 
and  then  died,  very  much  emaciated. 

“Another  dog  being  procured,  and  one  of  the  nerves  of  the  eighth  pa:, 
divided,  I allowed  six  weeks  to  elapse  before  the  other  was  cut  through 
This  division  of  the  corresponding  nerve  evidently  deranged  him,  but  in  a 
much  less  degree  than  in  the  former  experiments.”  It  was  not,  however, 
till  nearly  six  months  after  the  last  operation  that  he  fully  recovered  his 
health. 

This  recovery  of  the  functions  of  these  nerves,  might  either  depend  on 
enlargement  of  the  inosculating  twigs,  or  it  might  depend  on  the  reunion 
of  the  divided  extremities  of  the  nerves. 

“If  the  first  be  contended  for,  this  consequence  ought  to  ensue,  viz.  that 
the  eighth  pair  should  now  be  entirely  useless,  and  both  of  them  may  bc 
divided  a second  time,  without  injuring  any  of  the  functions  of  the  animal 

“If  the  last  be  granted,  it  must  of  necessity  follow,  that  the  medium 
of  union  possessed  the  same  properties  as  the  original  nerve. 

“I  have  now  circumscribed  the  field  of  inquiry,  and  have  drawn  the 
question  into  so  narrow  a compass,  that  it  is  in  the  power  of  a single  ex- 
periment to  prove  either  the  affirmative  or  negative..  If  now  the  eighth 
pair  be  divided  a second  time,  in  immediate  succession,  and  the  animal 
sustain  it  with  impunity,  1 conceive  it  right  to  conclude,  that  the  actions 
of  these  organs,  which  originally  were  carried  on  through  the  means  ol 
the  eighth  pair,  are  now  performed  by  other  channels,  ami  that  the  true 
substance  of  the  nerve  is  not  reproduced.  But,  on  the  contrary,  il  the 
animal  die  in  consequence  of  it,  then  I think  it  equally  just  to  inter,  tk.r 


OF  THE  HEAD  AND  NECK. 


313 


On  this  I would  ground  my  belief,  that  the 
recurrence  of  tic  douloureux  is  dependent  on  a 
reproduction  of  the  lost  substance,  and  conse- 
quent reunion  of  the  divided  extremities  of  the 
nerve.  I must  not,  however,  omit  mentioning, 
it  is  the  opinion  of  Mr.  Abernethy,  that  repro- 
duction of  the  disease,  is,  in  some  cases,  owing  to 
enlargement  of  the  anastomosing  branches  of  the 
divided  nerve.  This  opinion  was  fairly  deduced 
from  his  facts.  The  disease  was  seated  in  the  little 
finger,  and  many  remedies  had,  without  effect, 
been  tried.  The  affected  nerve  was  at  first  divi- 
ded, and  half  an  inch  of  its  substance  removed. 
The  operation  was  instantly  followed  by  loss  of 
sensation  in  the  part  on  which  the  nerve  was  dis- 
tributed— the  disease  seemed  to  be  removed  In. 
three  months  the  lady  had  regained  the  sensibility 
of  her  finger,  and  pressure  occasioned  a renewal 
of  the  unpleasant  feeling. 

From  the  recurrence  of  the  morbid  sensation 
in  the  finger,  after  the  removal  of  so  much  of 

the  new  formed  substance  is  really  and  Irul)  nerve,  because  we  know  of 
no  other  substance  which  can  perform  the  office  of  nerve. 

“1  shall  rely  then  on  the  following,  and  consider  it  as  my  exjierimentuni 
cruris: — 

“Having  the  dog  in  my  possession,  upon  which  I divided  the  eighth  pair 
of  nerves,  nineteen  months  before,  I cut  through  both  of  them  now,  in 
immediate  succession.  The  usual  symptoms  were  immediately  induced, 
and  continued  until  the  second  day,  when  he  died. 

“After  death,  I carefully  dissected  out  these  nerves,  and  have  presere 
ved  them  as  evidences  of  my  success  I think  1 have  now  answered  the 
question  I proposed  to  myselt,  and  can  affirm,  that  nerves  are  not  o.ijy 
capable  of  being  united,  when  divided,  but  that  the  nenv  formed  substance 
is  realty  and  'ruly  nerve.” 

40 


314 


ON  THE  SURGICAL  ANATOMY 


the  nerve,  Mr.  Abernethy  thinks  it  probable  that 
the  reproduction  of  the  disease  did  not  depend 
on  the  restoration  of  the  lost  substance,  but  was 
occasioned  by  an  enlargement  of  the  anastomosing 
twigs.  Dr.  Haighton’s  experiments,  and  other 
facts,  would  lead  me  to  doubt  the  correctness  of 
this  opinion.  The  operation  was  precisely  similar 
to  these  performed  on  the  portio  dura,  when  the 
surgeon  cuts  that  nerve  anterior  to  the  parotid 
gland,  one  of  its  branches  can  only  be  divided, — 
the  trunk  of  the  nerve  remains  untouched — the 
disease  recurs.  So,  in  like  manner  Mr.  Aberne- 
thy only  divided  a branch  of  the  ulner  nerve, 
the  branch,  indeed,  which  was  chiefly  affected: 
this  suspended  the  disease;  but  as  the  trunk  was 
entire,  the  complaint  in  time  recurred.  To  have 
been  conclusive,  Mr.  Abernethy  ought  to  have 
cut  out  a portion  of  the  trunk  of  the  ulner  nerve 
itself. 

Had  this  been  done,  and  had  the  disease  after- 
wards recurred,  he  might  reasonably  have  as- 
cribed the  reproduction  of  the  complaint  to  the 
agency  of  the  inosculating  twigs.  That  conclu- 
sion, although,  in  the  present  case,  at  first  sight 
plausible,  is  still  liable  to  the  objections  I have 
stated;  and  it  is  likewise  to  be  remembered,  that 
as  only  one  of  the  branches  of  the  nerve  supply- 
ing the  r.nger  was  operated  on,  and  as  the  other 
at  the  tip  of  the  finger  joins  freely  with  it,  and  as 


OF  THE  HEAD  AND  NECK. 


315 


both  have  a community  of  sensation,  no  wonder 
that  the  disease  should  ultimately  recur. 

I have  bestowed  so  much  attention  on  this 
point,  because  it  is  to  be  the  director  of  our  prac- 
tice; if  Mr.  Abernethy’s  doctrine  be  well  founded, 
no  operation  can,  in  tic  douloureux,  be  more  than 
a palliative  measure;  but  if  it  be  admitted,  that 
the  reproduction  of  the  complaint  depends  not 
on  an  enlargement  of  the  inosculating  twigs,  but  is 
occasioned  by  the  division  of  a branch  instead  of 
the  trunk,  we  shall  be  induced  to  hold  out  a pros- 
pect of  recovery  from  this  most  painful  disease. 

The  parotid  duct  is  a vessel  of  great  impor- 
tance: hence,  its  course  is  highly  necessary  to  be 
known  by  the  surgeon.  It  is  formed  by  twigs 
from  every  granule  of  the  gland.  As  these  unite, 
the  duct  increases  in  size,  and  as  it  increases,  it 
tends  forward,  and  finally  perforates  the  anterior 
margin  of  the  gland.  After  which,  it  immedi- 
ately applies  itself  to  the  surface  of  the  masseter 
muscle.  It  is  chiefly  where  traversing  this  mus- 
cle, and  while  dipping  from  its  edge  to  reach  the 
buccinator,  that  the  course  and  connexions  of  the 
parotid  duct  require  to  be  studied.  Its  course 
will  generally  be  defined  by  a line  extended  from 
the  junction  of  the  lobe  of  the  ear  and  figured 
portion,  to  midway  between  the  root  of  the  nose 
and  the  angle  of  the  mouth.  This  is  its  direct 
course  in  nine  out  of  ten  bodies;  but  there  are  many 
points  connected  with  the  history  of  this  duct, 


316 


ON  THE  SURGICAL  ANATOM! 


Very  necessary  to  be  understood — its  relation  to 
the  large  twigs  of  the  portio  dura — to  the  arteria 
transversalis  faciei-— to  the  socia  parotidis — to  the 
mass  of  fat  lodged  between  the  masseter  and  buc- 
cinator muscles,  and  to  the  fascial  art°ry  and  vein. 
Its  termination  must  also  be  familiar  to  the  stu- 
dent. How  it  is  contracted,  just  before  it  opens 
on  the  inner  surface  of  the  cheek,  and  the  exact 
place  of  its  perforation,  will  require  to  be  ex- 
plained. These  points  may  usefully  be  comment- 
ed on,  for  they  are  of  value  in  practice. 

In  its  whole  course,  the  parotid  duct  is  accom- 
panied by  twigs  from  the  portio  dura,  but  ex- 
cepting the  one  which  has  already  been  speci- 
fied as  running  between  the  zygoma  and  the 
duct,  none  of  them  are  large.  The  arteria  trans- 
versalis faciei,  arises  from  the  external  carotid, 
just  before  it  has  divided  into  the  internal  max- 
illary and  temporal  arteries,  or  from  the  latter 
artery.  Its  origin  is,  therefore,  deep  sunk  in 
the  substance  of  the  parotid  gland,  and  nearly  as 
low  as  the  commencement  of  the  parotid  duct. 
Presently,  however,  it  perforates  the  anterior 
margin  of  the  gland,  and  quits  its  former  course. 
It  inclines  upwards,  insomuch,  that  before  it  has 
reached  the  middle  of  the  masseter,  it  is  gene- 
rally placed  midway  between  the  parotid  duct 
and  the  zygoma.  At  this  part  it  lies  between 
the  socia  parotidis  and  the  masseter  muscle. 
While  here,  it  generally  breaks  down  into  nuraer- 


OF  THE  HEAD  AND  NECK.  31? 

oils  twigs,  some  of  which  twine  about  the  rami- 
fications of  the  portio  dura,  while  others  run  to 
the  fascial  muscles,  and  anastomose  with  the  twigs 
of  the  temporal,  the  internal  maxillary  and  fascial 
arteries. 

The  transverse  artery  of  the  face  is  seldom  of 
large  size;  never,  indeed,  except  when  it  supplies 
those  parts  which  ought  to  receive  blood  from  the 
facial  artery.  Then  it  assumes  a size  and  im- 
portance proportioned  to  the  number  of  parts 
which  it  has  to  support.  W'ien  the  labial  artery, 
where  turning  over  the  jaw  bone,  was  not  larger 
than  a sewing  thread,  I have  seen  the  transverse 
facial  artery  equal  to  the  diameter  of  a goose  quill. 
But  in  this  subject,  it  furnished  the  coronary 
artery  of  both  lips,  as  well  as  the  nasal  arteries. 
It  also  ran  nearer  to  the  parotid  duct  than  it 
usually  does,  when  the  labial  artery  is  of  its  com- 
mon size. 

Connected  with  the  parotid  duct,  the  trans- 
verse artery  of  the  face,  and  the  twigs  of  the 
portio  dura,  and  covering  part  of  the  masseter 
muscle,  we  find  the  socia  parotidis,  a texture  in 
every  respect  similar  to  the  parotid  gland,  secret- 
ing a similar  fluid,  and  pouring  it  by  one  or  more 
little  orifices  into  the  parotid  duct.  The  socia 
parotidis,  however,  is  neither  uniform  in  its  size, 
nor  constant  in  its  place,  and  is  even  in  some  sub- 
jects altogether  wanting.  Where  it  exists,  it 
sometimes  presents  the  appearance  of  a broad 


318 


ON  THE  SURGICAL  ANATOM V 


thin  patch;  at  other  times,  there  are  two  patches, 
or  it  is  collected  into  a little  knob.  Sometimes  it  is 
continued  from  the  edge  of  the  parotid  gland,  ac- 
companying the  parotid  duct  to  the  anterior  mar- 
gin of  the  masseter  muscle.  But  these  are  the  an- 
omalies of  the  socia  parotidis.  To  represent  it  as 
it  usually  appears,  it  must  be  described  as  a little 
glandular  process  lying  between  the  parotid  duct 
and  the  zygoma,  generally  in  close  contact  with,  or 
even  overlapping  the  former,  and  seated  some- 
what nearer  to  the  parotid  gland  than  the  middle 
of  the  masseter  muscle.  Frequently  one  or  two 
little  conglobate  glands  are  found  in  the  vicinity  of 
the  socia  parotidis. 

Leaving  these  parts,  the  parotid  duct  dips 
from  the  anterior  margin  of  the  masseter,  over 
the  mass  of  fat  which  is  interposed  between  that 
muscle  and  the  buccinator.  When  it  comes  in 
contact  with  the  buccinator,  it  suddenly  contracts 
to  a very  small  size;  in  its  previous  course  it  is 
about  the  thickness  of  a large  crow  quill,  and  its 
canal  will  admit  a common  sized  probe;  but  where 
passing  through  the  buccinator  muscle,  its  orifice 
will  hardly  admit  a catheter  wire.  It  usually 
opens  into  the  mouth  opposite  to  the  space  be- 
tween the  second  and  third  molar  teeth  of  the 
upper  jaw,  a little  below  the  margin  of  the  gum. 
Just  before  its  termination,  the  parotid  duct  is 
crossed,  and  touched  by  the  facial  vein,  but  the 


OF  THE  HEAD  AND  NECK. 


319 


artery  inclines  considerably  nearer  to  the  angle  of 
the  mouth. 

After  pointing  out  the  situation  of  the  portio 
dura,  the  parotid  duet,  the  socia  parotidis,  the 
transverse  artery  of  the  face,  and  the  facial  arte- 
ry and  vein,  a few  remarks  on  the  extirpation  of 
tumours  from  this  part  of  the  face  will  not  be 
out  of  place. 

In  removing  tumours  from  this  region,  it  ought 
to  be  a primary  consideration  to  avoid  injury  of 
either  of  these  parts,  but  more  especially  of  the 
parotid  duct,  which  occasions  a most  troublesome 
fistula.  All  this  can,  generally,  in  the  extirpa- 
tion of  tumours,  be  guarded  against.  Let  the 
student  make  himself  fully  acquainted  with  the 
line  which  the  parotid  duct  follows,  with  its  rela- 
tion to  the  masseter  muscle  and  the  buccinator; 
let  him  bear  in  remembrance  the  conglobate 
glands  which  are  in  the  vicinity  of  the  duct,  and 
let  him  not  overlook  the  mass  of  fat  which  fills 
up  the  space  between  the  buccinator  and  masseter 
muscles.  If  he  be  familiar  with  these  points,  he 
will  have  little  to  dread  in  extirpating  a tu- 
mour from  the  side  of  the  face,  nor  will  he  find 
much  difficulty  in  avoiding  the  parotid  duet. 

There  are  two  spots  chiefly  where  tumours 
form,  in  which  the  parotid  duct  is  concerned;  it 
will  hardly  be  necessary  for  me  to  add,  that  the 
one  is  where  the  duct  is  crossing  the  masseter 
muscle,  and  the  other  where  it  is  passing  from 


320 


ON  THE  SURGICAL  ANATOMY 


the  edge  of  that  muscle  to  reach  the  buccinator. 
In  the  former  case  the  tumour  is  usually  produced 
by  swelling  of  one  of  the  little  conglobate  glands 
which  lie  by  the  side  of  the  socio  parotidis;  in 
the  latter,  the  tumour  is  originally  formed  by  dis- 
ease of  the  bundle  of  fat  which  occupies  the  hol- 
low between  the  masseter  and  buccinator  muscles, 
or  by  enlargement  of  a lymphatic  gland  lodged 
among  that  fat.  The  latter  is,  perhaps,  a rare 
occurrence. 

When  a glandular  tumour  has  formed  over  the 
masseter,  the  parotid  duct  will  either  be  found 
lying  directly  behind  it,  or  it  will  be  displaced 
by  the  enlargement  of  the  swelling;  but  in  either 
case  it  will,  generally,  by  tearing  with  the  fin- 
gers, be  easily  separated  from  the  morbid  parts. 
Where,  however,  the  tumour  is  formed  by  the 
contents  of  the  space  between  the  masseter  and 
buccinator  muscles,  the  position  of  the  duct  will 
vary  according  to  the  nature  of  the  morbid  parts. 
Where  the  tumour  is  adipose,  and  continues  soft 
and  pliant,  if  it  have  projected  to  any  consider- 
able extent  from  between  the  muscles,  the  duct 
will  be  more  or  less  indented  into  the  morbid 
parts,  or  even  fairly  encircled  by  them.  Not 
only  the  parotid  duct,  but  the  facial  vein  also, 
may  be  sunk  into  such  a tumour.  The  duct  and 
vein  can  only  be  connected  in  this  manner,  with 
tumours  of  a soft  texture.  I have  seen  it  sur- 
rounded by  an  adipose  tumour,  by  a fungus 


OF  THE  HEAD  AND  NECK. 


321 


bsematodes  tumour,  and  by  an  anastomosing 
aneurism.  In  hard  glandular  swellings,  the  duct  is 
projected  on  the  front  of  the  morbid  parts,  or 
it  is  pushed  aside.  Let  these  facts  be  studied, 
and  we  shall  not  hear  surgeons  talk  of  extir- 
pating indiscriminately,  and  in  the  same  way, 
the  different  varieties  of  tumours  which  form 
about  the  face.  They  will,  on  the  contrary,  re- 
member, that  the  relation  of  the  parotid  duct,  and 
other  parts,  will  be  varied  according  to  the  posi- 
tion or  nature  of  the  morbid  parts.  They  will 
even  be  able  to  judge  pretty  accurately  whether 
it  will  be  found  behind,  or  on  the  front,  or  sunk 
into  the  substance  of  the  swelling. 


PLATE  VII. 

Fig.  1.  and  Fig.  2.  are  plans  illustrative  of  tumours  con- 
nected with  the  parotid  duct.  Fig.  1.  shews  a tumour, 
glandular  but  not  very  firm,  seated  over  that  portion  of 
the  duct  which  traverses  the  masseter  muscle.  Not  only 
the  duct,  but  also  some  of  the  twigs  of  the  portio  dura,  are 
connected  with  the  posterior  surface  of  the  swelling.  It 
will  be  necessary  to  explain  those  parts  in  order:  A is  the 
little  glandular  and  slightly  knobbed  swelling,  B repre- 
sents that  portion  of  the  parotid  duct  nearer  to  the  gland 
than  the  tumour,  and  C that  part  anterior  to  the  tumour. 
D is  the  facial  vein,  which,  in  its  course,  is  seen  traversing 
the  buccinator  muscle,  and  crossing  the  termination  of  the 
parotid  duct.  E the  facial  artery,  very  serpentine  in  its 
course,  and  observed  from  where  it  turns  over  the  jaw 

n 


322 


ON  THE  SURGICAL  ANATOMY 


bone  up  to  the  angle  of  the  mouth  inclining  forward,  and 
crossed  just  at  the  angle  of  the  mouth  by  the  insertion  of 
F,  the  zygomaticus  major  muscle. 

Fig.  2.  is  a plan,  shewing  the  relation  of  the  parotid 
duct  to  a tumour  which  has  protruded  from  between  the 
masseter  and  buccinator  muscles.  It  is  a tumour  of  a soft 
texture,  so  soft,  indeed,  that,  even  although  not  large,  the 
the  duct  is  indented  inffi  its  surface,  and  would,  had  the 
tumour  continued  to  increase,  have  been  fairly  buried 
deep  in  its  substance.  This  species  of  tumour  is  closely 
connected  with  the  duct.  A A is  the  swelling.  B B B the 
parotid  duct,  which  runs  over  the  anterior  part  of  the 
tumour.  C is  the  facial  vein,  covered,  along  part  of  its 
course,  by  the  tumour. 

A tumour  of  this  size  may  easily  be  extirpated,  and  the 
parotid  duct  saved,  provided  the  morbid  parts  have  not 
formed  adhesion  to  the  cheek.  When,  however,  the  cheek 
and  tumour  are  incorporated  into  one  mass,  the  facial  vein 
cannot  escape;  buried  in  the  diseased  parts,  it  must  be  re- 
moved along  with  them.  This  is,  however,  a trifling  cir- 
cumstance, compared  with  what  is  sometimes  required  to 
be  done.  It  is  an  absolute  nothing,  in  comparison  with 
what  must  be  done  and  taken  away  where  the  gums  are 
involved . 

In  this  sketch  the  tumour  is  circumscribed;  nitched,  in- 
deed, into  the  small  and  confined  space  between  the  mas- 
seter and  buccinator  muscle,  but  so  free  from  attachment 
to  the  parts  in  the  vicinity,  so  well  defined,  a mere  knob, 
that  except  from  the  position  of  the  parotid  duct,  there 
could  have  been  no  difficulty  in  its  excision.  It  is  one 
of  the  most  favourable  cases  which  a surgeon  cau  expect 
to  meet.  It  is  one  where  there  ought  to  be  no  hesitation, 
regarding  the  propriety  of  operation.  I would  even  give 
the  patient  a chance,  where  the  tumour  simply  adhered  to 


OF  THE  HEAD  AND  NECK. 


323 


t'he  cheek;  but  I would  never,  on  any  consideration,  or 
under  any  circumstances,  attempt  the  extirpation  of  a tu- 
mour when  connected  to  the  gums.  The  mangling  and 
scraping,  and  the  risk  of  previous  absorption,  and  the 
almost  physical  impossibility  of  removing  completely  the 
whole  of  the  diseased  parts,  preclude,  in  my  opinion,  any 
reasonable  prospect  of  success  for  such  an  operation.  To 
attempt  it,  therefore,  conscious  as  we  must  be  that  it  can- 
not succeed,  is  only  putting  the  patient  to  the  pain  of  a 
fruitless  operation.  It  is  unquestionably  the  duty  of  every 
surgeon  to  undertake  an  operation,  even  where  the  pros- 
pect of  success  is  not  very  great;  but  it  surely  cannot  be 
incumbent  on  him  to  attempt  what  he  is  fully  aware  he 
cannot  execute.  I believe  there  is  no  one  instance  in 
which  recovery  has  taken  place,  where  an  operation  had 
been  performed  under  such  circumstances;  nay,  there  are 
very  few  surgeons  who  would  either  advise  or  perform  the 
operation. 

Mr.  John  Bell  did,  in  the  case  of  Mr.  Taylor,  endeavour 
to  extirpate  an  extensively  diseased  mass  from  the  hollow 
of  the  cheek;  a mass  covered  by  very  unhealthy  skin,  rough3 
discoloured,  warty,  and  puckered,  and  firmly  fixed  to  the 
gums.  This  Mr.  Bell  hoped  to  dig  away  at  the  expense  of 
the  parotid  duct  and  the  facial  vessels;  but  although  he  cut 
widely,  sparing  nothing  which  savoured  of  disease,  still 
the  issue  was  unfortunate.  The  complaint  recurred,  and 
ultimately  killed  the  patient. 


That  a tumour  has  formed  between  the  mas- 
seter  and  buccinator  muscles,  is  ascertained  by 
examination  with  a finger  introduced  into  the 
mouth.  In  this  way  a projection  will  be  diseov- 


324 


ON  THE  SFftGICAL  ANATOMY 


ered  just  between  the  gums  of  the  upper  and 
lower  jaws,  extending  some  way  forward,  and 
pushing  the  cheek  inward.  When  the  tumour  is 
solid  in  its  consistence,  has  continued  for  a length 
of  time,  is  not  perceptibly  moveable,  or,  when 
moved,  carries  along  with  the  lining  membrane 
of  the  cheek,  and  when  this  membrane  feels  in- 
durated, and  the  patient  cannot  freely  open  the 
mouth,  it  may  be  inferred  that  the  morbid  parts 
have  extended  backward  behind  the  ascendint 
plate  of  the  maxilla  inferior  and  the  buccinator* 
lodging  themselves  between  the  internal  and  ex. 
ternal  pterygoid  muscles. 

Such  a case  is  hopeless;  an  operation  is  ouv 
of  the  question;  no  prudent  surgeon  would  proposes 
it,  nor  any  intelligent  patient,  when  apprized  of 
the  danger,  insist  on  its  performance  Yet,  al- 
though under  such  circumstances,  the  surgeon 
has  it  not  in  his  power  to  extirpate  the  morbid 
parts,  still  he  is  not  to  desert  the  patient.  I have 
known  a solid  tumour  of  this  kind,  which  had 
continued  for  a considerable  time,  and  which  had 
completely  curbed  the  motions  of  the  jaw,  ab- 
sorbed. 

The  patient  was  under  the  care  of  Dr.  Brown, 
with  whom  I saw  him.  He  was  a stout  young 
man,  with  a fulness  on  the  one  side  of  the  face, 
just  before  the  edge  of  the  masseter  muscle.  This 
muscle  was  rigid,  and  the  limits  of  the  tumour 
externally,  were  not  distinctly  marked — there 


OF  THE  HEAD  AND  NECK. 


325 


Was  a gradual  change  from  induration  to  natural 
texture.  Internally,  a hard  knob  was  readily 
discovered  pushing  inward  the  lining  membrane 
of  the  cheek.  This  tumour  extended  as  far  back 
as  the  finger  could  reach,  which  was  not  very  far, 
since  the  mouth  could  not  be  opened.  Although, 
therefore,  it  could  not  be  proved,  by  actual  exa- 
mination, still  it  was  evident,  from  the  effects 
produced,  that  the  tumour  must  have  extended 
deep  behind  the  ascending  plate  of  the  lower 
jaw  bone.  Its  nature,  connexions,  and  position, 
were  altogether  such  as  to  forbid  any  operation. 
Various  local  remedies  were  tried,  but  the  tu- 
mour did  not  begin  to  decrease  till  sometime  after 
a seton  had  been  passed  through  the  skin  below 
the  jaw.  At  last  it  was  completely  removed  by 
the  absorbents. 

The  result  of  this  case  was  highly  satisfactory, 
yet  it  is  not  mentioned  for  the  purpose  of  recom- 
mending local  remedies  in  preference  to  the  knife; 
it  is  brought  forward  to  shew,  that  even  in  the 
worst  of  cases,  perseverance  may  do  good.  It 
never  can  furnish  an  apology  for  neglecting  to 
remove  a tumour  of  a similar  kind,  when  within 
the  reach  of  an  operation. 

In  extirpating  tumours,  the  primary  considera- 
tion with  the  surgeon  ought  to  be,  to  remove  the 
morbid  parts  without  injuring  the  capsule  which 
defines  them.  If  he  accomplish  this,  he  has  no- 
thing to  dread  from  a return  of  the  disease. 


326  ON  THE  SURGICAL  ANATOMY 


Where,  however,  he  nibbles  at  the  tumour  with 
the  knife,  and  cuts  it  away  piece  meal,  he  has  no 
security;  amidst  the  blood  and  confusion  he  can 
never  say  when  the  whole  is  taken  away;  much 
may  be  left,*  or  too  much  may  be  removed,  the 
clear  bed  of  the  tumour  can  never  be  fairly  ex- 
posed. 

There  is  every  reason,  therefore,  to  induce  an 
operator  to  plan  his  operation  so,  that  the  tu- 
mour may  be  cut  out  entire;  nor  about  the  face, 
will  this  be  so  difficult  as  many  would  imagine. 
The  parotid  duct  is  to  be  avoided.  Its  relation 
to  the  tumour,  it  has  been  seen,  will  vary  accord- 
ing to  the  locality  of  the  latter,  but  fortunately, 
these  variations  can  generally  be  pretty  accu- 
rately ascertained  before  beginning  our  operation. 

To  this,  however,  we  must  never  trust;  our 
dependence  for  the  safety  of  this  vessel  must  be 
placed  in  exposing  the  duct  nearer  to  the  parotid 
gland  than  the  tumour.  If  this  be  done,  its  firm- 
ness will  be  its  protection  during  the  subsequent 
progress  of  the  operation. 

The  tumour,  in  those  cases  where  the  duct  lies 
behind  it,  is  to  be  exposed  on  every  side,  either 
by  a careful  dissection  with  the  scalpel,  or  by 
working  with  the  fingers.  In  whatever  way  its 
lateral  connexions  are  destroyed,  its  final  separa- 

* If  it  would  serve  any  useful  purpose,  I could  relate  different  cases  from 
my  own  observation,  to  corroborate  this  assertion;  at  present,  however,  I 
have  more  than  one  reason  for  declining  the  task. 


OF  THE  HEAD  AND  NECK. 


327 


tion,  from  its  adhesion  to  the  parts  behind,  is  to 
be  accomplished  by  the  fingers.  This  will  sel- 
dom be  difficult,  never  indeed,  unless  where  the 
capsule  of  the  tumour  has,  by  inflammatory  adhe- 
sion, been  fixed  to  the  neighbouring  parts.  Then, 
no  doubt,  it  is  less  easily  accomplished,  but  still, 
by  care  and  cautious  working  with  the  nails,  it 
may  be  removed  without  injury  of  either  its  cap- 
sule, or  of  the  parotid  duct.  These  are  to  be 
sedulously  guarded  against;  the  first  secures  the 
patient  from  a return  of  the  disease;  the  second 
from  the  formation  of  a salivary  fistula. 

The  excision  of  tumours  lying  anterior  to  the 
parotid  duct,  is  generally  very  simple,  but  the 
removal  of  those  in  which  the  duct  lies  before 
the  tumour,  is  more  difficult;  and  where  the  duct 
is  imbedded  in  the  morbid  parts,  we  can  seldom, 
where  the  tumour  is  of  a specific  nature,  accom- 
plish a cure.  Considering  the  greater  difficulty 
of  extirpating  tumours  lying  behind  the  parotid 
duct,  it  is  the  duty  of  the  surgeon  to  enforce 
the  early  removal  of  every  swelling,  situated  be- 
tween the  masseter  and  buccinator  muscles.  If 
executed  while  the  tumour  is  small,  and  as  freely 
moveable  as  its  confined  situation  will  permit,  the 
surgeon  may  reasonably  hope  to  be  able  to  extir- 
pate it  fully.  If,  however,  he  delay  till  it  has  be- 
come wedged  into  that  hollow,  till  it  has  formed 
firm  adhesion  to  the  surrounding  parts,  and  till 
the  cheek  has  become  indurated,  all  reasonable 


328 


ON  THE  SURGICAL  ANATOMY 


hope  from  an  operation,  must  be  at  an  end.  It 
may  be  attempted,  but  cannot  succeed. 

From  this  view  it  will  appear,  that  no  time 
ought  to  be  lost  in  attempts  to  discuss  such  tu- 
mours by  external  applications.  Here  an  opera- 
tion must  be  speedily  performed,  or  the  patient 
must  resolve  to  run  all  hazard.  Better,  there- 
fore, that  a surgeon  should  unnecessarily  extirpate 
a simple  glandular  swelling,  than  that  he  should, 
on  the  presumption  of  a tumour  being  simple, 
permit  it  to  gain  ground,  and  form  connexions, 
from  which,  were  it  really  of  a specific  nature, 
lie  could  not  afterwards  detach  it. 

Since  this  sheet  was  sent  to  press,  I have  been 
consulted  by  a gentleman  regarding  a tumour  on 
the  cheek,  which  began  some  years  ago,  soon  af- 
ter the  extraction  of  one  of  the  molar  teeth  from 
the  upper  jaw.  It  has,  since  its  commencement, 
continued  slowly  to  increase  in  size;  it  is  now  as 
large  as  an  orange,  elastic  when  touched,  free 
from  pain,  but  covered  by  thin  integuments  of  a 
reddish  purple  colour.  It  extends  from  the  an- 
terior margin  of  the  masseter  muscle,  to  the  angle 
of  the  mouth,  and  reaches  from  the  lower  edge  of 
the  orbit,  to  the  alveolar  processes  of  the  lower 
jaw.  Between  the  mouth  and  the  tumour,  there 
is  only  a membrane  interposed;  not  thicker  than 
writing  paper,  but  the  morbid  parts  are  perfectly 
moveable;  they  have  little  connexion  either  with 
the  skin,  or  lining  membrane  of  the  cheek. 


OF  THE  HEAD  AND  NECK. 


329 


The  tumour  seems  to  be  simply  steatomatous, 
and  its  connexions  are  not  of  such  a nature,  as  to 
forbid  an  operation  The  parotid  duct,  some  of 
the  branches  of  the  portio  dura,  and  the  facial  ar- 
tery and  vein,  will,  no  doubt,  be  implicated,  but 
they  could  surely  be  extricated;  our  objection  to 
an  operation,  is  the  general  state  of  the  patient’s 
health,  and  his  advanced  period  of  life. 

He  is  above  sixty,  and  has  been  an  irregular 
living  man;  his  constitution  seems  injured,  his 
nose  is  carbunculous,  and  the  skin  of  his  face  is 
far  from  having  a healthy  appearance.  When  I 
view  these  facts,  and  take  into  consideration  the 
thinness  of  the  integuments  covering  the  tumour, 
and  separating  it  from  the  mouth,  I cannot  divest 
myself  of  a fear,  that  adhesion  would  not  take 
place  after  the  excision  of  the  tumour.  It  is  pro- 
bable, that  in  a constitution  such  as  this  gentle- 
man possesses,  the  wound  would  slough,  inducing 
that  febrile  condition  so  inimical  to  the  success  of 
any  operation.  On  this  account  I dissuaded  the 
patient  from  urging  the  extirpation  of  the  swelling, 
which  he  wished  to  have  removed. 

In  extirpating  a tumour  seated  behind  the  pa- 
rotid duct,  the  first  point  is  to  expose  the  duct, 
just  where  passing  from  the  edge  of  the  masseter; 
then  it  is  to  be  traced  forward  along  the  whole 
extent  of  the  tumour.  In  doing  this,  the  duct  is 
to  be  left  attached  to  the  integuments  on  one 
4% 


330 


ON  THE  SURGICAL.  ANATOMY 


side;  then  with  the  fingers,  the  coverings  of  the 
tumour  and  the  duct  are  to  be  turned  aside,  a 
hook  is  to  be  struck  into  the  tumour,  which  will 
generally,  from  the  quantity  of  loose  fat  in  which 
it  lies  imbedded,  be  easily  pulled  outward,  when 
it  may  be  detached,  by  snipping  with  the  scissors 
the  fatty  process  by  which  it  is  connected  to  the 
deep  seated  parts.  By  cutting  this,  the  nutrient 
vessels  of  the  tumour,  which  are  derived  from 
the  internal  maxillary  artery,  will  generally  be 
divided,  but  they  will  seldom  be  found  of  such 
a size,  as  to  require  the  ligature. 

To  some,  it  may  seem  that  in  describing  the 
external  incision  along  the  course  of  the  parotid 
duct,  I have  overlooked  the  risk  of  injuring  the 
facial  vein.  This  is  really  inconsiderable;  gene- 
rally the  vein  is  pushed  towards  the  angle  of  the 
mouth  by  the  tumour,  but  even  if  it  did  lie  over 
the  morbid  parts,  and  if  it  were  cut  across,  it 
would  prove  of  very  little  consequence. 

Where  the  tumour  lies  either  anterior  or  pos- 
terior to  the  parotid  duct,  it  can,  and  consequent- 
ly ought  to  be  removed  with  its  capsule  entire: 
but  when  the  duct  is  imbedded  in  a fatty  mass, 
the  sheath  of  the  morbid  parts  must  be  cut  into, 
and  the  tumour  extirpated  in  two  portions.  Where 
the  disease  is  not  of  a specific  nature,  the  duct 
may  be  safely  extricated,  and  a cure  accomplish- 
ed; but  where  the  duct  is  imbedded  in  a specific 
tumour,  it  is  hardly  possible  to  dissect  it  out,  with- 


OF  THE  HEAD  AMD  NECK, 


331 


<out  some  of  the  morbid  substance  adhering  to  it. 
I would,  therefore,  in  such  a case,  prefer  cutting 
out  the  portion  of  the  duct  connected  with  the 
tumour,  to  any  attempt  to  extricate  it.  Where, 
however,  the  tumour  is  not  of  a specific  nature, 
I can  confidently  speak  of  the  propriety  of  dis- 
secting the  duct  out  of  the  substance  of  the  swel- 
ling. 

In  extirpating  an  anastomosing  aneurism  from 
the  living  subject,  I have  found  it  necessary  to 
dissect  the  parotid  duct,  and  a large  branch  of  the 
portio  dura,  from  amongst  the  substance  of  the 
tumour,  so  as  to  insulate  them  completely  along 
nearly  three  quarters  of  an  inch  of  their  course. 
To  the  result  of  this  operation,  I would  call  the 
attention  of  the  student.  It  was  such,  as,  a pri- 
ori, might  have  been  inferred  from  Mr.  Hunter’s 
experiments  on  adhesion.  As  the  case  to  which 
I have  alluded  is  interesting,  I shall  transcribe  it 
from  my  note  book: 

“A  middle-aged  and  stout  young  man,  lately 
applied  to  me  for  advice,  respecting  a large,  livid, 
and  compressible  tumour,  which  was  seated  in 
the  vicinity  of  the  right  orbit.  On  inquiring,  I 
was  told  that  the  swelling  had  existed  from  his 
birth,  that  it  was  sometimes  more  distended  than 
at  other  times,  that  it  seldom  was  productive  of 
pain,  except  when  injured,  on  which  occasion  it 
poured  out  a considerable  quantity  of  fluid  blood. 
The  patient  likewise  stated,  that  the  tumour 


332 


ON  THE  SURGICAL  ANATOMY 


never  pulsated  nor  throbbed,  but  during  exertion 
or  walking  during  a very  hot  or  very  cold  dayf 
it  became  exceedingly  tense. 

‘‘Externally  the  tumour  covered  about  one- 
third  of  the  temporal  extremity  of  the  upper  eye- 
lid; it  likewise  occupied  the  whole  extent  of 
the  lower  one,  the  folds  of  which  were  sepa- 
rated by  the  blood  to  such  an  extent,  as  to  pro- 
duce an  unseemly,  irregular,  and  pendulous  swell- 
ing. which  hung  down  over  the  cheek.  Towards 
the  outer  canthus  of  the  eye,  the  morbid  texture 
was  interposed  between  the  tunica  conjunctiva 
and  the  sclerotic  coat,  forward,  to  within  the 
eighth  part  of  an  inch,  of  the  attachment  of  the 
lucid  cornea.  It  was  chiefly  in  this  direction, 
that  the  disease  was  spreading.  From  the  ex- 
ternal angle  of  the  eye  the  tumour  was  prolonged 
both  outwards  and  tfownwTards.  In  the  first  direc- 
tion, it  extended  to  the  point  of  junction  of  the  tem- 
poral and  malar  bones;  in  the  latter,  it  descended 
nearly  half  an  inch  below  the  line  of  the  parotid 
duct. 

“Through  its  whole  extent,  the  tumour  was  free 
of  pulsation;  no  large  artery  could  be  traced  into 
it;  by  pressure,  it  was  readily  emptied  of  its  con- 
tents; but  slowly,  on  the  removal  of  the  pressure, 
it  was  again  filled.  When  emptied,  by  rubbing 
the  collapsed  sac  between  the  fingers,  a doughy 
impression  was  communicated  to  them.  On  the 
surface,  it  was  of  the  dark  purple  colour  of  the 


OF  THE  HEAD  AND  NECK. 


335 


grape,  with  a tint  of  blue  on  those  parts  covered 
by  the  skin,  but  where  invested  by  the  tunica  con- 
junctiva, it  had  a shade  of  red.  It  was  cold  and 
flabby,  communicating  to  the  fingers  the  same  sen- 
sation which  is  received  on  grasping  the  wattles 
of  a turkey  cork.7’ 


DESCRIPTION  OF  PLATE  VIII. 

Fig.  1 — This  figure  affords  an  accurate  representation 
of  the  situation  and  external  character  of  the  aneurismal 
tumour  just  described.  The  course  of  the  parotid  duct, 
may  be  shewn,  by  a line  drawn  from  the  junction  of  the 
lobe  with  the  cartilaginous  portion  of  the  ear,  to  the  point 
intermediate  between  the  root  of  the  nose  and  the  angle  of 
the  mouth.  The  situation  of  the  branch  of  the  portio  dura, 
which  was,  along  with  the  parotid  duct,  dissected  from  the 
diseased  substance,  will  be  readily  remembered.  It  lies  a 
little  nearer  to  the  zygoma  than  the  parotid  duct.  These 
are  the  chief  points  which  this  drawing  is  meant  to  illus- 
trate; yet  it  will  also  have  its  use  in  explaining  the  extent 
of  the  tumour,  and  its  connexions  with  the  eye-lids. 


aAs  the  tumour  was  increasing,  and  threatened 
to  extend  over  the  eye,  the  patient  was  anxious  for 
its  removal.  By  a careful  examination,  I was  sa- 
tisfied that  it  might  be  extirpated;  the  arteria 
transversalis  faciei,  the  largest  branch  of  the  por* 


33 4 ON  THE  SURGICAL  ANATOMY 


tio  dura,  and  the  parotid  duct,  would  unquestiona- 
bly be  found  more  or  less  connected  with  it.  On 
the  sixth  of  May,  I performed  the  operation,  in 
presence  of  Dr.  Balmanno,  Dr.  Brown,  and  Dr. 
King;  and  was  assisted  by  Mr.  Russell. 

“I  began  by  detaching  the  lower  eye-lid  along 
its  whole  extent,  then  I readily  enough  dissected 
away  that  part  of  the  tumour  adhering  to  the 
sclerotic  coat,  and  I next  removed  that  portion  of 
the  tumour  which  adhered  to  the  upper  eye-lid. 
This  being  done,  I tied  a pretty  large  artery, 
which  passed  into  the  tumour  from  the  outer  and 
lower  part  of  the  orbit.  The  vessel  lay  just  to  the 
temporal  side  of  the  inferior  oblique  muscle.  The 
next  stage  of  the  operation  consisted  in  dissecting 
off  the  tumour  clearly  from  the  aponeurosis  of  the 
temporal  muscle — the  zygomatic  process — from 
the  malar  bone,  and  from  over  the  large  branch  of 
the  portio  dura,  and  the  parotid  duct.  After  the 
great  body  of  the  tumour  was  in  this  way  removed, 
I found  that  still  a part  of  the  spongy  morbid  mass 
remained  attached  to  the  parts  behind  the  parotid 
duct,  and  portio  dura;  1 also  discovered  that 
some  of  the  tumour  dipped  beneath  the  fascia  of 
the  temporal  muscle,  which  was  reticulated. 

“From  these  parts  there  was  a general  oozing 
of  blood,  and  from  the  divided  transverse  facial 
artery,  as  well  as  from  the  arteries  which  perfo- 
rated the  malar  bone  and  the  masseter  muscle, 
there  was  a pretty  profuse  bleeding.  The  vessels 


OF  THE  HEAD  AND  NECK. 


335 


I secured,  and  then  with  the  forceps  and  scissors 
I cleared  away  the  diseased  matter  from  behind 
the  parotid  duct  and  branch  of  the  portio  dura, 
both  of  which  were  thus  detached  from  all  con- 
nexion with  the  neighbouring  parts.  In  the  same 
way  I was  obliged  to  cut  out  a quantity  of  diseased 
substance  from  behind  the  zygoma.  As  the  mor- 
bid parts  were  here  ill  defined,  and  much  inter- 
mixed with  the  fibres  of  the  temporal  muscle,  a 
considerable  part  of  it  required  to  be  taken  away; 
now,  in  doing  this,  the  deep-seated  anterior  tem- 
poral artery  was  divided.  What  of  it  remained 
on  the  cheek  adhered  so  firmly  to  the  zygomatic 
muscle,  and  was  so  closely  incorporated  with  its 
substance,  that  the  one  could  not  be  separated 
from  the  other. 

“In  performing  the  latter  part  of  the  operation 
no  large  artery  was  divided,  and  all  those  which 
had  been  cut  were  secured,  yet  there  still  conti- 
nued a considerable  oozing  from  the  surface  of 
the  malar  bone,  and  from  about  the  zygoma. 

“Immediately  after  the  operation,  the  insulated 
part  of  the  portio  dura  and  of  the  parotid  duct 
were  laid  back  on  the  masseter  muscle,  and  the 
edges  of  the  integuments  were  kept  in  contact 
over  them,  by  means  of  a single  suture.  Over 
the  malar  bone  the  lips  of  the  wound  could  not  be 
made  to  approach,  nor  did  the  oozing  from  the 
bone  cease.  A fold  of  linen  and  a layer  of  sponge, 
were  therefore  laid  into  this  part  of  the  wound, 


336 


ON  THE  SURGICAL  ANATOMY 


and  retained  there  by  a compress  and  bandage, 
applied  so  tightly  as  to  restrain  the  bleeding. 

“The  sponge  was  kept  firm  in  its  place  during 
two  days,  then  it  was  removed  without  a renewal 
of  the  bleeding.  So  soon  as  the  sponge  was 
taken  away,  we  endeavoured  with  strips  of  adhe- 
sive plaster,  to  bring  the  lips  of  the  wound  nearer 
to  each  other.  The  sore  soon  began  to  form  gra- 
nulations, which,  in  a few  days,  notwithstand  ng 
the  use  of  regulated  pressure,  became  so  luxu- 
riant, that  they  had  risen  considerably  above  the 
level  of  the  wound.  They  had  not  a healthy 
look,  but  on  the  contrary  formed  a flabby  red 
fungus,  perfectly  unconnected  with  the  margins  of 
the  sore. 

“Although  the  granulations  did  not  shew  any 
tendency  to  form  skin,  yet  the  sore  was  daily 
reduced  by  the  approximation  of  its  edges.  An 
eschar  was  repeatedly  formed  on  the  surface  of 
the  granulations,  by  the  application  of  sulphate 
of  copper,  without  the  effect  of  checking  their 
exuberant  growth,  or  disposing  them  to  form 
skin.  Still,  however,  by  bringing  the  edges  of 
the  sore  nearer  to  each  other,  its  limits  were  re- 
duced, and  in  the  end  were  brought  to  a size  little 
larger  than  the  diameter  of  a shilling,  without 
apparently  the  cicatrization  of  a single  granula- 
tion. When  the  sore  was  reduced  to  this  diame- 
ter, new  skin  began  to  extend  from  the  margin 
over  the  granulations,  which,  before  the  end  of 


OP  THE  HEAD  AND  NECK. 


337 


July,  were  completely  covered  by  a new  formed 
pelicle  of  skin,  which  occasioned  a very  little  de- 
formity of  the  countenance.” 

It  is  now  more  than  three  years  since  the  sore 
was  healed,  and  still  the  patient  continues  free 
from  any  return  of  the  disease,  and  the  cica- 
trix is  becoming  smaller.  The  only  inconveni- 
ence which  the  patient  now  experiences,  arises 
from  the  motion  of  the  upper  eye-lid,  being  im- 
paired by  its  adhesion  to  that  part  of  the  sclero- 
tic coat  from  which  the  tumour  had  been  dis- 
sected. From  the  same  cause,  the  ball  of  the 
eye  does  not  possess  the  same  latitude  of  motion 
as  formerly.  It  requires  a considerable  effort  to 
turn  the  pupil  toward  the  nose. 

This  case  is  not  only  valuable  in  so  far  as  it 
illustrates  the  surgery  of  the  side  of  the  face; 
but  it  is  also  interesting,  as  illustrative  of  one 
species  of  anastomosing  aneurism. 

In  the  aneurism  from  anastomosis,  there  is  no 
loss  of  muscularity — no  dilatation  of  the  coats  of 
the  vessels  from  weakness;  there  is  no  partial 
growth  from  any  individual  artery;  but,  on  the 
contrary,  the  tumour  is  formed  by  an  enlargement 
of  the  inosculating  twigs.  By  the  dilatation  of 
vessels,  which  in  the  healthy  state,  would  hardly 
have  been  visible  to  the  naked  eye,  the  pulsating 
mass  is  composed.  This  is,  therefore,  a disease 
of  a singular  nature,  and  its  characters  are  so  de- 
eidedly  marked,  that  we  cannot  but  wonder  that 
43 


33S  ON  THE  SURGICAL  ANATOMY 


it  should,  till  so  lately,  have  almost  completely 
escaped  notice.  It  is  most  unquestionably  cer- 
tain, that  hints  of  its  existence  are  to  be  met  with 
in  more  ancient  works  than  Mr.  Bell’s  Principles 
of  Surgery;  but  they  were  so  vague,  and  had  so 
little  effect  in  calling  the  attention  of  surgeons  to 
this  affection,  that  Mr.  Bell  is  justly  considered 
the  first  who  accurately  described  aneurism  from 
anastomosis — a disease  which  differs  widely  from 
true  aneurism. 

In  anastomosing  aneurism,  the  blood  remains 
always  fluid  in  the  vessels,  and  these,  though 
enlarged,  still  retain  their  contractibility,  and 
are  still  competent  to  the  propulsion  of  their  con- 
tents by  their  own  action.  The  structure  of  the 
tumour  is  also  altogether  unlike  that  of  true 
aneurism.  The  blood,  in  place  of  being  lodged 
in  a circumscribed  sac,  is  contained  in  the  ex- 
treme vessels,  which  are,  in  this  disease,  much 
enlarged  and  exceedingly  active. 

Mr.  John  Bell  describes  the  tumour  as  made 
up  of  a cellular  structure  like  the  placenta,  and 
into  each  cell  he  tells  us  an  artery  opens  and 
a vein  rises  from  it.  In  this  disease  there  is  “ a 
violent  action  of  the  arteries,  and  a mutual  en- 
largement of  the  arteries  and  veins;  while  the 
intermediate  substance  of  the  part  is,  by  this  im- 
pulse, and  in  course  of  time,  slowly  distended 
into  large  intermediate  cells,  which  dilate  at 
last  into  formidable  reservoirs  of  blood.” — “The 


OF  THE  HEAD  AND  NECK. 


339 


veins  form  a conspicuous  part  of  such  a tumour, 
but  the  intermediate  cells  are  as  sensible  a part 
of  the  structure;  for  when  the  tumour  is  emp- 
tied, we  feel  that  the  blood  is  repressed  from 
the  sacs  in  the  veins;  and  when  the  tumour  is 
large,  with  a purpled  surface,  we  feel  the  sacs 
individually  prominent;  when  they  burst  we  see 
the  blood  flow  out  from  them;  and  when  the  tu- 
mour is  extirpated,  they  seem  to  compose  its  chief 
bulk.” 

“The  altered  structure  of  the  part  resembles, 
then,  that  imaginary  parenchyma  or  cellular  sub- 
stance which  the  early  anatomists  of  Europe  pre- 
sumed, and  indeed  pretended  to  prove  by  injec- 
tion, was  interposed  betwixt  the  extremities  of 
the  arteries  and  those  of  the  veins  in  all  parts  of 
the  body,  especially  in  the  secreting  viscera.” 

These  are  Mr.  Bell’s  observations  on  the  struc- 
ture of  such  tumours,  and  it  is  but  justice  to  add 
that  they  are  corroborated  by  Mr.  Freer,  who 
has  injected  one  of  these  tumours  with  mercury, 
so  as  satisfactorily  to  demonstrate  its  cellular 
structure.  Other  pathologists  deny  the  existence 
of  these  cells,  affirming  that  the  tumour  is  entirely 
composed  of  a congeries  of  coiled  up  vessels. 

I can  readily  conceive  how  both  Mr.  Bell  and 
Mr  Freer  may  have  been  deceived.  Till  the 
time  of  the  illustrious  Haller,  it  was  currently 
believed  that  the  vesiculse  seminales  were  cellular. 
This  anatomist  unraveled  them,  and  observed 


340 


ON  THE  SURGICAL  ANATOMY 


that  they  were  really  composed  of  convoluted 
tubes.  Were  I to  speak  from  my  own  observation, 
regarding  the  texture  of  the  tumour  in  anastomos- 
ing aneurism.  I would  certainly  be  inclined  to 
believe  that  it  was  really  cellular. 

There  would  seem  to  be  two  species  of  anasto- 
mosing aneurism:  one  in  which  the  arteries  are 
chiefly  affected,  and  another  in  which  the  veins 
are  principally  concerned.  The  I rst  is  an  acute 
and  most  dangerous  disease;  the  latter  is  chronic 
and  less  to  be  dreaded. 

The  arterial  anastomosing  aneurism  begins 
from  a mark  which  had  existed  as  a discoloured 
spot  from  birth:  or  it  appears  at  first  like  a small 
fiery  pimple,  or  it  succeeds  a blow  or  some  other 
injury,  or  it  begins  without  any  obvious  exciting 
cause.  In  whatever  way  it  begins,  it  is  at  first 
small,  but  gradually  increases  in  size;  the  pulsa- 
tion, which  originally  was  obscure,  becomes  a 
prominent  feature  in  the  complaint,  the  swelling 
still  enlarges,  the  pain  and  feeling  of  distension 
augments,  “and  when  the  cells  are  enlarged  into 
sacs,  and  the  mutual  communications  consequently 
free  betwixt  the  extreme  arteries  and  veins,  the 
whole  tumour  pulsates  distinctly,  and  when  ex- 
cited by  exertion  or  muscular  struggles,  it  throbs 
furiously;  the  tumour  assumes  then  a purple  hue; 
the  apices  of  the  sacs  become  sensibly  thin:  the 
patient  is  alarmed  from  time  to  time  with  slighter 
haemorrhages,  which  becoming  more  frequent 


OF  THE  HEAD  AND  NECK. 


341 


from  various  points,  and  very  profuse,  he  is  at 
last  debilitated,  changes  his  complexion  and 
colour,  loses  his  health,  and  dies.” 

From  the  first  to  the  last  the  swelling  is  com- 
pressible, and  it  is  even  more  easily  reduced  in 
size  by  pressure,  in  the  advanced,  than  in  the 
early  stage,  when  it  is  “of  a doughy  consistence, 
and  having  a woollen  or  cushion  like  feeling, 
when  pressed  and  moulded  under  the  finger.” 
In  the  latter  stage,  in  those  cases  which  I have 
seen,  the  tumour  was  easily  emptied;  but  on  the 
removal  of  the  pressure,  was  almost  instanta- 
neously filled  by  one,  two  or  three  large  tortuous 
arteries  which  could  be  traced  into  its  substance, 
and  which  were  left  beating  much  more  vigorous- 
ly than  the  arteries  in  any  other  part  of  the  body. 
The  working  of  these  arteries  and  the  labouring 
of  the  tumour,  when  the  circulation  is  hurried  by 
exertion,  or  increased  by  hot  weather,  is  most 
dreadfully  increased.  And  during  these  periods 
of  excitement,  it  is  proper  to  mention,  that  the 
heat  of  the  tumour,  as  measured  by  the  thermome- 
ter, is  actually  greater  than  the  temperature  of 
the  other  parts  of  the  body. 

From  the  description  of  anastomosing  aneurism, 
it  will  appear  to  be  a peculiar  affection  of  the  vas- 
cular system,  and  therefore  not  to  be  treated  on 
the  general  principles  applicable  to  true  aneurism. 
In  the  latter,  we  tie  the  great  artery  considerably 
above  the  aneurismal  spot,  and  we  allow  the  tu- 


342 


ON  THE  SURGICAL  ANATOMY 


mour  to  decay  from  operations  carried  on  within 
itself;  in  the  former,  we  must  proceed  on  a very 
different  principle,  for  were  we  to  rest  satisfied  by 
securing  the  arteries  passing  into  the  tumour,  we 
would  only  suspend  its  growth  till  the  collateral 
vessels  had  enlarged.  So  soon  as  this  took  place, 
and  experience  proves  that  it  is  not  a tedious  ope- 
ration, the  tumour  would  again  be  supplied  with 
blood,  and  would  again  resume  its  peculiar  char- 
acter, and  proceed  in  the  extension  of  its  limits. 
Any  attempt,  therefore,  to  cure  this  disease,  by 
ligature  of  the  arteries  which  support  it,  is  entirely 
out  of  the  question.  Mr.  John  Bell  strenuously 
argues  the  necessity  of  cutting  out  all  the  diseased 
parts;  and  in  equally  decided  terms,  reprobates 
any  interference  where  we  judge  this  to  be  im- 
practicable. This  seems  to  be  the  generally  re- 
ceived opinion  of  surgeons  on  this  subject;  and  it 
was  one,  the  propriety  of  which  I never  ventured 
to  call  in  question,  till  I accidentally  witnessed  a 
case,  which  shewed  in  the  most  striking  manner, 
the  expediency  of  acting  differently,  under  certain 
circumstances. 

My  brother  was  requested  to  visit  Mr. , 

on  Wednesday  the  18th  of  October,  1809,  about 
seven  o'clock  in  the  morning.  He  went,  and 
found,  that  during  the  night,  the  gentleman  had 
lost  a great  quantity  of  blood,  from  a wound  which 
had  been  made  about  fourteen  days  before  by  a 
surgeon  who  had  opened  the  temporal  artery,  on 


OF  THE  HEAD  AND  NECK. 


3 43 


account  of  an  apoplectic  affection.  The  wound 
had  never  healed,  neither  was  this  the  first  time 
he  had  been  alarmed  by  profuse  bleeding  from  it. 
Means  had,  indeed,  been  employed  to  prevent  the 
haemorrhage,.  Compression  had  been  tried,  and 
an  attempt  had  even  been  made  by  a practitioner 
to  tie  the  trunk  of  the  injured  artery.  But  neither 
the  one  nor  the  other  proving  effectual,  my  bro- 
ther was  called  in  on  the  third  day  after  the  ap- 
plication of  the  ligature.  He  desired  that  I would 
visit  the  patient  along  with  him. 

When  we  examined  him,  he  was  complaining  of 
considerable  pain  and  tenderness  along  the  side  of 
the  head,  which  was  greatly  distended.  The  in- 

t< 

teguments  over  the  temporal  muscle,  the  eyelids, 
and  the  right  side  of  the  face,  were  swollen  by 
effusion  into  the  cellular  membrane.  The  finger, 
when  pressed  firmly  on  those  parts,  sunk  deep, 
and  the  pit  remained  for  some  minutes.  We  now 
directed  our  attention  to  the  parts  more  immedi- 
ately concerned  with  the  bleeding,  and  were  sur- 
prised on  finding  the  wound  filled  by  a tumour, 
oblong  and  about  the  size  of  a hazel  nut — of  a pur- 
plish colour — beating  in  unison  with  the  action  of 
the  arteries — easily  compressed,  but  becoming  in- 
stantaneously, on  withdrawing  the  pressure,  full 
and  tense;  and  from  a small  orifice,  projecting 
with  great  impetus,  a stream  of  arterial  blood. 

We  could  have  no  doubt  that  this  was  an  anas- 
tomosing aneurism — the  ready  compression  of  the 


344 


ON  THE  SURGICAL  ANATOMY 


defined  purple  tumour — its  throbbing  and  hard- 
working under  the  restraint  of  pressure — its  full 
and  rapid  distension  on  removing  the  pressure — 
the  copious,  though  small  stream  of  pure  blood, 
which  sprung  from  the  lacerated  looking  hole, 
and  the  strong  pulsation  of  the  trunk  and  branch- 
es of  the  temporal  artery,  were  characters  which 
no  one  could  mistake.  They  established  in  the 
most  decided  manner,  the  nature  of  the  disease, 
which,  as  yet,  appeared  manageable. 

The  beating  tumour  was  circumscribed,  and  of 
small  size:  the  diffused  swelling  had  the  appear- 
ance of  arising  from  intersticial  fluid  effused  be- 
neath the  skin;  only  the  temporal  artery  could  be 
felt  pulsating  with  unusual  vigour,  and  not  even  a 
twig  of  the  frontal  artery  could  be  traced  into  the 
diseased  part;  nor  could  any  undulation  be  per- 
ceived in  any  part  beyond  the  limits  of  the  tu- 
mour. This  circumscribed  swelling  was  situated 
about  midway  between  the  zygoma  and  the  mar- 
gin of  the  planum  semicirculare,  just  over  the 
fib]  ts  of  the  temporal  muscle,  and  we  supposed 
exterior  to  the  fascia  of  that  muscle. 

On  a full  review  of  the  case,  and  on  taking 
into  consideration  the  nature  of  the  disease  we 
had  to  contend  with,  the  failure  of  pressure,  and 
the  attempt,  which  without  benefit,  had  been 
made  to  secure  the  artery,  we  resolved  on  dis- 
secting out  the  tumour.  My  brother,  with  a 
full  and  instantaneous  sweep  of  the  scalpel,  first 


OP  THE  HEAD  AND  NECK. 


345 


#n  the  one  side,  and  then  on  the  other,  insulated 
the  tumour  from  its  lateral  connexions,  and  with- 
out loss  of  time,  finished  the  removal  of  the 
morbid  parts,  by  separating  them  from  their  deep- 
seated  connexions.  In  doing  this,  it  was  found 
necessary  to  take  away  a part  of  the  temporal 
muscle.  So  soon  as  this  was  done,  blood  gushed 
from  behind  the  zygoma,  and  from  innumerable 
pores  in  the  situation  of  the  temporal  muscle  it 
spurted  with  impetuosity  and  per  saltern.  No 
sooner  had  the  wound  been  cleared  with  the 
sponge,  than  it  was  filled  and  overflowed.  The 
trunk  of  the  temporal  artery  still  laboured  vio- 
lently, and  we  now  found  that  pressure  on  this 
vessel  did  not  interrupt  the  bleeding. 

The  disease,  which  before  operation  appeared 
to  have  been  circumscribed,  was  in  reality  widely 
extended.  It  descended  beneath  the  zygoma — 
was  incorporated  with  the  substance  of  the  tem- 
poral muscle;  hence  the  body  of  the  tumour  was 
firmly  bound  down,  by  the  aponeurosis  of  the 
temporal  muscle,  and  was  liberally  fed  with  blood 
by  the  temporal  branches  of  the  internal  maxil- 
lary artery.  When  the  tumour  was  cut  out,  the 
base  of  the  wound  could  readily  be  compress- 
ed by  the  thumb  thrust  down  behind  the  zygoma; 
but  so  soon  as  the  pressure  was  removed,  it 
heaved,  worked,  and  puffed  up,  till  it  rose  to  the 
level  from  which  it  had  been  squeezed.  . Ai!  this 
was  accomplished  in  an  instant,  and  was  followed 


346 


ON  THE  SURGICAL  ANATOMY 


by  most  impetuous  bleeding.  We  plainly  saw 
that  it  was  out  of  the  reach  of  surgery  to  dig  out 
the  placenta-looking  spongy  pulsating  mass  from 
its  recesses  behind  the  cheek  hone. 

Had  this  been  resolved  on  during  the  attempt 
to  execute  our  purpose,  the  patient  must  have 
lost  a great  quantity  of  blood;  and  after  all,  I do 
not  believe  that  the  diseased  parts  would  have 
been  fully  taken  away.  Under  these  circumstan- 
ces, we  were  reluctantly  compelled  to  thrust  a 
sponge,  firmly  wedged  down  behind  the  zygoma, 
and  afterward  we  trusted  the  prevention  of  hae- 
morrhage to  compression  kept  up  by  the  twisted 
bandage. 

The  tumour  which  was  removed  had  quite  the 
usual  structure  of  anastomosing  aneurism.  The 
ease  was  curious,  however,  because,  although  the 
disease  was  extended  deep  behind  the  malar  bone, 
still  as  the  morbid  parts  were  bound  down  by  the 
strong  aponeurosis  of  the  temporal  muscle,  ex- 
cept at  the  point  where  the  external  swelling  w’as 
seated,  no  pulsation,  no  undulation,  nor  motion 
of  any  kind  could  be  perceived,  except  at  that 
spot.  The  short  duration  of  the  complaint,  and 
the  apparent  small  size  of  the  tumour,  deceived 
us  as  to  the  real  extent  of  the  disease,  and  led 
us  to  operate.  But  so  soon  as  the  superficial  part 
of  the  tumour  was  taken  away,  we  saw  enough  to 
convince  us,  that  any  further  attempt  in  the  way 
of  cutting,  would  have  been  fruitless. 


OF  THE  HEAD  AND  NECK. 


347 


It  was  not  with  superficial  arteries  we  had  to 
eontend;  on  the  contrary,  it  was  with  branches 
so  sunk  into  a deep  and  inaccessible  hollow,  that 
had  we  even  completed  the  removal  of  the  whole 
of  the  diseased  parts,  still  the  bleeding  must  have 
been  commanded  by  the  sponge.  We,  therefore, 
in  using  the  pressure  at  the  time  we  employed 
it,  had  a two -fold  object  in  view;  our  primary  en- 
deavour was  to  restrain  the  haemorrhage,  but  we 
trusted  that  if  the  pressure  could  be  steadily  and 
firmly  kept  up  for  a sufficient  length  of  time,  it 
would  not  only  prevent  the  bleeding,  but  we 
hoped,  that  it  would  also  produce  a consolida- 
tion, or  destruction  of  what  remained  of  the  dis- 
eased substance.  Such  was  our  wish — how  well 
we  succeeded,  will  be  learned  from  the  subsequent 
history  of  the  case. 

On  Monday,  the  23d,  all  the  dressings  were 
removed  except  the  sponge,  which  remained  firm- 
ly wedged  in  behind  the  zygoma,  and  likewise 
adhered  firmly  to  the  bottom  of  the  wound  above 
the  zygoma.  There  had  been  no  haemorrhage, 
and  very  little  secretion  of  pus,  but  the  little 
which  had  been  formed,  was  very  fetid.  The 
edges  of  the  wound  looked  clean  and  healthy. 

On  the  29th,  the  sponge  was  equally  firm  as 
at  last  dressing.  On  slightly  moving  it,  a small 
quantity  of  blood  oozed  from  its  side.  There 
was  no  appearance  of  reproduction  of  the  tu- 
mour. 


348  ON  THE  SURGICAL  ANATOMTT 

Till  the  sixth  of  November  the  suonge  coin 
tinned  slrwly  to  be  detached,  and  on  that  day  it 
fc.  me  away,  leaving  the  base  of  the  sore  healthy, 
the  granulations  firm,  and  the  discharge  moderate. 
The  original  disease  was  completely  destroyed  by 
the  pressure  of  the  sponge,  which  was  kept  stea- 
dily in  its  place  by  the  twisted  bandage. 

After  the  sponge  came  away,  the  sore  daily 
contracted  in  its  dimensions,  and  in  a short  time 
was  completely  cicatrized.  The  beating  about  the 
head,  which  had  formerly  distressed  the  patient 
so  much,  and  for  the  removal  of  which,  the  tem- 
poral artery  had  been  opened  was  now  hardly 
complained  of,  and  the  general  health  was  much 
improved. 

The  operation  of  arteriotomy  had  been  twice 
performed  on  this  patient.  The  first  time  the 
temporal  artery  was  opened,  the  bleeding  readily 
ceased,  and  the  wound  healed  kindly.  On  the 
last  occasion,  the  bleeding  was  never  fully  com- 
manded, nor  did  the  wound  heal.  Its  lips  were 
forced  asunder  by  the  new  pulsating  growth, 
which  before  my  brother  was  called  in,  had  re- 
peatedly burst,  alarming  the  patient  and  his 
friends,  by  effusing  a prodigious  quantity  of  florid 
blood.  1 have  never  heard  of  any  patient  in  whom 
arteriotomy  acted  as  the  exciting  cause  of  anasto- 
mosing aneurism;  nor  am  I convinced  that  it  was 
the  exciting  cause  in  even  this  case.  The  tumour, 
although  connected  with  the  superficial  temporal 


OF  THE  HEAD  AND  tfECK. 


349 


artery,  was  more  intimately  connected  with  the 
deen  branches  of  the  internal  maxillary  artery. 

Were  speculation  warrantable,  it  might  be  sup-* 
posed  that  the  tumour  in  this  patient  had  exist- 
ed beneath  the  temporal  fascia,  before  the  artery 
had  been  opened — that  the  lancet  had  penetrated 
into  it  while  opening  the  vessel,  and  that  after- 
wards the  morbid  parts  had  sprouted  up  through 
the  incision  in  the  fascia,  and  involved  the  super- 
ficial arteries  in  the  propagation  and  extension  of 
the  disease.  It  is  hardly  conceivable,  that  had 
the  disease  been  first  excited  by  the  puncture 
into  the  temporal  artery,  it  could  in  the  short 
space  of  fourteen  days  have  extended  so  far  be- 
neath the  aponeurosis,  while  it  remained  so  small 
and  circumscribed  exterior  to  it.  The  superficial 
tumour  seemed  more  of  the  size  of  a fortnight’s 
growth,  than  the  deep  seated  one.  Indeed  it  is 
probable,  that  the  throbbing  and  unpleasant  sen- 
sations in  the  head,  which  called  for  the  per- 
formance of  arteriotomy,  had  been  produced  by  the 
working  of  the  deep-seated  tumour. 

It  is  a curious  circumstance,  that  the  operation 
of  opening  the  temporal  artery  should  have  un- 
folded the  true  nature  of  this  gentleman’s  com- 
plaint. I cannot  suppose,  that  in  saying  this  I 
eonvey  the  slightest  insinuation  against  the  me- 
dical attendants  for  their  not  having  sooner  ascer- 
tained the  precise  nature  of  the  case.  I rather 
point  out  a fact  hitherto  unnoticed  in  the  history 


350 


ON  THE  SURGICAL.  ANATOMY 


of  anastomosing  aneurism,  and  intended  to  show, 
that  where  the  tumour  is  seated  beneath  a firm 
and  unyielding  fascia,  its  working  and  healing 
may  escape  detection  by  external  examination, 
and  about  the  head  may,  to  the  patient,  convey 
the  feeling  as  if  it  were  within  the  cranium. 
Such  an  idea  may  lead  the  practitioner  to  a belief 
of  the  patient  i eing  threatened  with  apoplexy; 
and  may,  as  in  the  present  instance,  induce  him 
to  open  the  temporal  artery.  If.  in  doing  this,  he 
penetrate  the  aponeurosis,  he  will  soon  have  clear 
evidence  of  the  true  character  of  the  disease  he 
has  interfered  with. 

From  the  successful  result  of  the  firm  pressure 
employed  in  this  case,  I would  be  led  to  operate, 
even  where  I had  but  little  expectation  of  being 
able  to  remove  the  whole  of  the  diseased  sub- 
stance, provided  the  tumour  was  seated  over  a 
bone,  and  in  such  a position  that  I could  employ 
sufficient  compression. 

This  case  will  he  considered  as  valuable;  the 
characters  of  the  complaint  were  decided,  and  had 
the  extent  of  the  disease  been  previously  known, 
an  operation  would  not  have  been  undertaken; 
yet  the  issue  of  it  will,  I think,  establish  the 
propriety  of  giving  the  patient  the  chance  afforded 
by  an  operation,  even  although  from  the  circum- 
stances of  the  case,  we  know,  a priori,  that  it 
must  be  incomplete.  This  is  a position  directly 
the  reverse  of  that  laid  down  by  Mr.  John  Bell. 


OF  THE  HEAD  AND  NECK.  351 

who  tells  us  that  we  are  “not  to  cut  into,  but  to 
cut  it  out.”  This  I should  have  believed,  had 
I not  witnessed  the  beneficial  effects  of  an  oppo- 
site conduct  in  the  present  instance — a case  in 
which  there  was  no  alternative*  The  operation 
was  begun  under  the  impression  of  the  practica- 
bility of  extirpating  all  the  diseased  matter,  but  it 
was  soon  discovered  that  the  morbid  parts  could 
not  be  fully  dissected  away. 

We  were  much  pleased,  on  finding,  as  the 
sponge  came  away,  the  sore  looking  clean,  furnish- 
ing firm  and  healthy  granulations,  with  a moderate 
secretion  of  good  pus,  where  we  had  dreaded  a 
renewal  of  the  morbid  texture  and  bloody  dis- 
charge. I am  convinced  that  this  gentleman  owes 
his  recovery  to  the  operation  and  subsequent  com- 
pression; but  the  one  was  undertaken  on  the  idea 
that  the  disease  was  superficial  and  circumscribed, 
while  the  other  was  had  recourse  to,  in  order  to 
avoid  immediate  death,  which  would  have  been 
the  inevitable  consequence,  had  it  not  been  em- 
ployed. 

The  favourable  result  of  this  case  would  embol- 
den me  to  operate  in  even  a very  bad  case  of  this 
disease,  and  in  which  I could  have  no  hope  of  be- 
ing able  to  remove  with  the  knife  all  the  morbid 
parts;  but  I would  only  do  so  where  I had  it  in 
my  power  to  use  very  firm  pressure.  If  the  posi- 
tion of  the  tumour  was  such  as  not  to  permit  of 
this,  I would  most  cordially  conclude  with  Mr. 


352 


ON  THE  SURGICAL  ANATOMY 


Bell,  that  no  operation  ought  to  be  attempted;  as 
under  such  circumstances  it  would,  to  a certainty, 
accelerate  the  death  of  the  patient.* 

Such  is  the  nature  and  plan  of  treatment  to  be 
adopted  in  the  arterial  anastomosing  aneurism, 
which  is  more  fully  described,  although,  perhaps, 
not  more  frequent  in  its  occurrence,  than  the  ve- 
nous anastomosing  aneurism,  which,  in  nine  out 
of  ten  cases,  arises  from  a nsevus  maternus.  The 
case  which  I formerly  related,  in  which  the  paro- 
tid duct  was  dissected  out  of  the  substance  of  the 
tumour,  furnishes  an  epitome  of  all  that  requires 
to  be  said  on  this  subject.  I might,  no  doubt,  add 
other  cases  to  those  already  described,  but  these  I 
deem  sufficient.  They  are  so  decided  in  their 
character,  that  their  nature  cannot  be  mistaken; 
they  shew  the  marked  difference  which  exists  be- 
tween the  arterial  and  venous  anastomosing  aneu- 
rism. Different,  however,  as  they  are  in  some 
points,  and  unlike  as  they  are  in  their  general  fea- 
tures, the  practice  in  both  is  similar;  and  their  re- 
sult, if  the  disease  be  permitted  to  run  its  course, 
will  not  be  very  dissimilar. 

The  anterior  facial  vein,  begun  by  the  veins  of 
the  forehead,  is,  at  the  root  of  the  nose,  about  the 
diameter  of  a large  crow  quill.  In  its  descent  it 
touches  the  insertion  of  the  orbicularis  palpebra- 
rum, and  a little  lower  in  the  face  it  is  covered  by 
some  of  the  fibres  of  that  muscle.  It  runs  in  an 


See  Appendix  (E.) 


6F  THE  HEAD  AND  NECK,  353 

oblique  line  from  the  angle  of  the  eye  to  the  ante- 
rior margin  of  the  masseter  muscle.  About  ac. 
inch  below  the  junction  of  the  eye-lids,  but  consi- 
derably nearer  to  the  zygoma,  the  facial  vein  ge- 
nerally crosses  the  infra-orbitar  foramen.  Be- 
tween the  vein  and  the  infra-orbitar  nerve  and  ar- 
tery, there  is  only  the  thickness  of  the  levator  labii 
superioris  muscle  interposed.  Descending  lower, 
it  inclines  nearer  to  the  angle  of  the  jaw,  and  in 
its  course  crosses  the  parotid  duct.  Along  its 
whole  extent  the  facial  vein  lies  nearer  to  the  ear 
than  the  artery,  which,  however,  runs  parallel  to 
it,  and  nearly  in  contact  with  it,  from  a little  be- 
low the  angle  of  the  mouth  to  the  margin  of  the 
jaw  bone.  Along  that  part  of  the  face  these  ves- 
sels are  covered  by  the  scattered  fibres  of  the  pla- 
tysma  myoides. 

Opposite  to  the  angle  of  the  mouth  the  artery 
inclines  forwards,  and  at  the  same  time  mounts 
gently  upwards,  running  always  in  a waving 
course,  and  often,  about  this  part,  forming  one 
or  two  coils  on  itself.  About  midway  between 
the  margin  of  the  lower  jaw  and  the  mouth,  the 
arteria  labialis  superficialis  is  given  off.  Then  in 
succession,  and  at  a very  short  distance  from 
each  other,  the  facial  artery  gives  origin  to  the 
upper  and  lower  coronary  arteries,  which  are  im- 
mediately deeply  buried  in  the  substance  of  the 
lips.  To  this  point  the  attention  of  the  student 
must  be  directed;  he  ought  clearly  to  understand 
45 


354 


ON  THE  SURGICAL  ANATOMY 


that  there  is  only  the  lining  membrane  of  the  lip 
nearer  to  the  mouth  than  the  coronary  vessels. 
If  every  surgeon  were  aware  of  this  fact,  fewer 
mistakes  would  be  committed  in  dressing  the 
wound  after  operations  performed  on  the  lip. 

Many  surgeons,  knowing  no  better,  believe  that 
pins  are  passed  through  the  margins  of  the  wound, 
solely  for  the  purpose  of  keeping  them  in  contact. 
With  this  object  in  view,  they  pass  them  in  such 
a way,  that  the  cut  edges  are  carefully  kept  in 
contact  in  front,  but,  so  that  they  are  allowed  to 
recede  from  each  other  behind.  But  although  re- 
tention of  the  divided  surfaces  in  contact,  forms  a 
primary  consideration  in  employing  pins,  still  it  is 
not  the  only  one;  the  operator  is  really  desirous 
at  the  same  time  that  he  keeps  the  lips  of  the 
wound  together,  to  prevent  haemorrhage  from 
the  divided  coronary  arteries.  The  latter  object 
can  only  be  accomplished,  by  passing  the  pin 
completely  behind  the  artery  between  it  and  the 
investing  membrane  of  the  lip,  directly  opposite 
or  nearly  so,  to  the  point  where  the  vessel  is 
seated.  Let  an  operator  do  this,  and  no  bleeding 
can  take  place,  neither  can  the  edges  of  the 
wound  stand  gaping  behind;  let  him  pass,  how- 
ever, the  pins  in  front  of  the  artery,  and  there 
is  no  security  that  bleeding  shall  not  take  place; 
on  the  contrary,  we  know  that  it  has  frequently 
happened.  Some  patients  soon  after  an  operation 
become  faint,  and  arteries  even  larger  than  the 


OF  THE  HEAD  AND  NECK. 


355 


eoronary  vessels  of  the  lips  cease  to  effuse  blood. 
If  in  this  state  of  the  circulation,  the  surgeon  pass 
the  pins  in  front  of  the  arteries  and  finish  the 
dressing  of  the  wound,  every  thing  for  a time  will 
go  on  well. 

The  patient  is  desired  to  avoid  speaking  or 
spitting,  and  he  is  enjoined  to  swallow  whatever 
flows  into  his  mouth.  He  obeys  his  instructions — 
he  revives  and  as  he  recovers,  blood  runs  from 
the  divided  arteries  back  into  the  mouth;  it  is  swal- 
lowed, and  I have  actually  known  a patient  to  ad- 
here so  pointedly  to  his  directions,  as  to  swallow 
such  a quantity  of  blood,  as  occasioned  a dreadful 
sickness  and  severe  vomiting,  during  which  the 
lips  of  the  wound  were  burst  asunder,  and  the 
pins  torn  from  their  hold;  new  pins  required  to  be 
passed,  but  the  margins  of  the  wound  were  now 
ragged  and  irritated — the  cure  was  retarded,  and 
the  patient  compelled  to  suffer  much  unnecessary 
pain.  By  a little  attention  on  the  part  of  the 
operator  all  this  may  be  avoided.  If  fine  pins  be 
employed,  the  mark  left  by  them  is  very  trifling. 
In  cuts  about  the  lips  and  face,  I have  repeatedly 
employed  fine  sewing  needles,  which  are  equally 
adapted  for  the  purpose,  as  gold  or  silver  pins. 
If  the  points  of  the  needle  be  carefull  cleaned,  and 
as  Mr.  John  Bell  properly  advises,  if  they  be  well 
oiled,  they  will  be  found  to  enter  very  smoothly, 
and  with  less  pain.  When  they  are  to  be  with- 
drawn, let  them  be  first  rotated  and  then  extract- 


356  ON  THE  SURGICAG  ANATOMY 

ed.  To  obtain  a firmer  hold  of  them,  Mr.  Bell 
passes  a thread  through  the  eye  of  each  needle.* 

After  the  origin  of  the  upper  coronary  artery, 
the  continued  branch  of  the  facial  artery  mounts 
along  the  side  of  the  nose,  more  superficial  than 
the  levator  angu'i  oris,  but  covered  by  the  levator 
labii  superioris  alseque  ilasi.  It  then  covers  the 
wing  of  the  nose  with  its  twigs,  but  is  not  by  this 
quite  exhausted,  it  still  ascends  till  at  the  root  of 
the  nose  it  receives  additions  from  the  orbit. 
The  slender  branch  formed  by  the  union  of  these 
reaches  the  forehead,  where  it  is  lost  in  inoscula- 
tion, with  the  ophthalmic  and  temporal  arteries. 

The  lachrymal  sac  is  sunk  into  the  recess  be- 
tween the  margin  of  the  orbit  and  the  tendon  of 
the  orbicularis  palpebrarum.  The  fibres  of  that 
muscle  cover  the  3ac,  and  also  the  ducts  continued 
from  the  puncta  lachrymalia.  The  sac,  which 
is  of  an  oblong  shape,  is  placed  with  the  taper- 
ing extremity  turned  downwards.  From  the  most 
depending  part  of  the  sac  the  nasal  duct  arises. 
It  opens,  by  a small  rounded  mouth  into  the  nos- 
tril, about  half  an  inch  behind  the  ascending 
plate  of  the  jaw-bone,  and  nearly  opposite  to 
the  middle  of  the  inferior  spongy  bone  It  is  to 
be  recollected,  that  the  margins  of  this  aperture 
are  membranous  and  loose,  even  in  some  instan- 
ces puckered,  a conformation  which  sometimes 
obstructs  the  entrance  of  the  probe.  As  the 

* Bell  on  Tumours,  page  208. 


OF  THE  HEAD  AND  NECK.  357 

Surgeon  is  often  called  on  to  decide  regarding 
the  state  of  the  duct,  it  may  be  proper  to  make  a 
few  remarks  on  the  mode  of  examining  this 
canal. 

The  introduction  of  the  probe  is  not  generally 
difficult,  yet  I have  seen  several  foiled  in  their 
endeavours  to  pass  it.  They  attempted  by  force 
what  they  ought  to  accomplish  by  artifice; 
they  endeavoured  without  an  acquaintance  with 
the  mechanism  of  the  parts,  to  do  wtiat  can 
only  be  done  by  one  who  is  familiar  with  the  or- 
ganization. The  position  of  the  orifice  of  the 
nasal  duct,  and  the  after  course  of  the  canal,  ought 
to  be  carefully  studied,  because  the  probe  must 
be  adapted  to  the  curve  of  these  parts.  It  is  to 
be  passed  by  gentle  efforts;  force  must  never 
be  employed.  I pass  the  probe  along  the  floor 
of  the  nostril,  with  its  concavity  directed  towards 
the  antrum,  and  its  convexity  looking  towards  the 
septum  of  the  nose.  I carry  it  on  in  this  course 
till  I feel  that  its  point  has  passed  beyond  the  as- 
cending plate  of  the  jaw  bone;  then  I rotate  the 
probe  between  my  fingers,  till  its  point  looks  up- 
ward and  outward  toward  the  eye.  While  the 
probe  is  making  this  turn,  it  is  of  consequence 
that  its  point  be  maintained  in  close  contact  with 
the  side  of  the  nostril.  When  this  turn  is  com- 
pleted, the  handle  of  the  probe  is  to  be  gently 
depressed,  while  its  body  and  point  are  elevated. 
This  motion  conveys  its  point  into  the  orifice  of 


358  ON  THE  SURGICAL  ANATOMY 

the  nasal  duct,  and  carries  it  up  into  the  lachry- 
mal sac. 

If  the  duct  be  free  from  obstruction,  this  is 
generally  readily  accomplished;  but  it  must  be 
mentioned,  that  where  the  lining  membrane  of  the 
nostril  is  preternaturally  loose  and  pendulous,  the 
point  of  the  probe  sometimes  catches  a fold  of  it, 
which  is  carried  into  the  orifice  of  the  duct, 
where  as  a valve,  it  hinders  the  further  progress 
of  the  instrument.  This  cause  of  obstruction  is 
most  easily  overcome,  by  retracing  the  probe  a 
little,  and  moving  its  point  slightly  away  from  the 
side  of  the  nostril. 


DESCRIPTION  OF  PLATE  IX. 

This  sketch  illustrates  many  points  connected  with  the 
operations  performed  on  the  nose.  The  chief  object  it  is 
intended  to  explain,  is  the  situation  of  the  termination  of 
the  nasal  duct,  A,  which  opens  just  behind  the  upper  bor- 
der of  the  lower  spongy  bone.  The  spongy  bone  has  been 
displaced,  to  bring  into  view  this  opening,  which  is  na- 
turally overhung  by  the  bone.  The  probe  must  therefore 
be  insinuated  between  the  nasal  process  of  the  superior 
maxillary  bone,  and  the  lower  spongy  bone,  before  its 
point  can  be  conveyed  into  the  duct.  These  parts  are  de- 
lineated of  their  natural  size,  hence  it  will  be  seen,  that 
the  orifice  of  the  nasal  duct  is  deeper  seated  than  many 
imagine.  It  is  from  not  being  aware  of  this  fact,  that 
some  surgeons,  who  attempt  to  give  the  turn  too  soon  to 
the  point  of  the  probe,  are  disappointed  in  their  endea- 


I3 late  g . 


Engraved,  by  X Cone. 


/ 


OF  THE  HEAD  AND  NECK. 


359 


vours  to  get  it  into  the  duct.  Let  the  student  examine 
this  sketch,  and  he  will  see  the  spot,  where  he  ought  to 
turn  the  probe  into  the  orifice  of  the  duct. 

Besides  shewing  the  place  of  the  nasal  duct,  this  plate 
also  represents  the  situation  of  the  opening,  leading  from 
the  nostril  into  the  maxillary  sinus.  This  apperture  B,  is 
placed  in  the  middle  meatus  of  the  nose.  In  the  natural 
state,  it  is  completely  overhung  and  concealed  from  view, 
by  the  upper  spongy  bone.  To  expose  it,  considerable 
liberty  has  been  taken  with  the  spongy  bone.  It  has  in- 
deed been  broken  from  its  connexions  with  the  sethmoid 
bone.  From  the  slanting  manner  in  which  this  duct  en- 
ters the  nose,  I conceive  that  no  fluid  can  pass  from  the 
sinus  into  the  nose,  neither  is  it  practicable  to  introduce 
a probe  from  the  nostril  into  the  antrum.  This  I would 
insist  on,  since  it  will  correct  our  notions  regarding  the 
office  of  the  antrum,  and  unfold  the  absurdity  of  the  pro- 
posal made  by  some,  of  introducing  an  instrument  by  the 
nostril  into  the  maxillary  sinus  in  some  of  its  diseases. 

It  will,  I believe,  be  found,  that  in  the  healthy  state  of 
the  lining  membrane  of  the  antrum,  no  more  fluid  is  se- 
creted by  its  vessels,  than  can  be  easily  re-absorbed  by  its 
lymphatics;  secretion  and  absorption  balance  each  other. 
But  sometimes  by  disease  the  secretion  is  increased  be- 
yond what  the  absorbents  can  remove — hence  the  fluid  ac- 
cumulates in  the  antrum;  little  can  naturally  pass  from 
the  sinus  into  the  nostril,  and  the  greater  the  quantity  col- 
lected in  the  cavity,  the  less  can  pass  from  it,  because  the 
opening  is  so  formed,  that  whenever  fluid  is  collected  in 
considerable  quantity  in  the  sinus,  it  presses  the  one  lip 
of  the  opening  against  the  other.  Urine  might  as  readily 
regurgitate  from  the  bladder  along  the  ureter,  as  fluid  pass 
from  the  antrum  into  the  nose. 

From  this  mechanism,  fluid  collected  in  the  antrum  can- 
not escape,  and  owing  to  the  same  cause,  when  it  would 


360 


ON  THE  SURGICAL  ANATOMY 


be  necessary  to  open  a passage  for  it,  we  cannot  accom- 
plish it,  by  passing  a probe  along  the  natural  opening,  as 
in  the  case  of  obstructed  nasal  duct.  A new  passage  must 
be  formed,  and  we  know  that  it  may  be  most  conveniently 
formed,  by  extracting  one  of  the  grinding  teeth,  and  per- 
forating from  its  socket  into  the  antrum.  Indeed,  in  many 
subjects,  the  fangs  ol  these  teeth  have  little  except  the 
lining  membrane  of  the  sinus  interposed  between  them  and 
the  cavity  of  the  sinus.  In  every  case,  the  solid  substance 
is  so  trifling,  that  no  difficulty  can  be  experienced  in  passr 
ing  through  it. 

I would  also  call  the  attention  of  the  student  to  the  ca- 
nal of  communication  between  the  frontal  sinus  and  the 
nostril,  which  opens  at  C,  into  the  middle  meatus  of  the 
nose.  A knowledge  of  the  situation  of  this  opening,  and 
the  direction  of  the  canal,  may  be  of  use  to  him  in  cases, 
where  insects  have  nestled  in  the  sinus  He  may,  by  this 
information,  be  enabled  to  introduce  such  substances  into 
the  sinus,  as  will  destroy  them.  1 have  in  my  possession, 
a worm  dislodged  in  this  way  from  the  frontal  sinus. 

The  opening  of  the  eustachian  tube  D,  ought  likewise  to 
be  noticed.  The  form  of  its  trumpet  like  orifice,  and  its 
position  at  the  root  of  the  pterygoid  process  of  the  sphenoid 
bone,  ought  to  be  familiar  to  the  surgeon.  This  know- 
ledge will  enable  him  to  pass  a probe  from  the  nostril  along 
the  tube,  in  cases  of  deafness,  supposed  to  depend  on  ob- 
struction of  this  canal.  Where  the  deafness  is  produced 
by  mucus  impacted  in  the  mouth  of  the  tube,  one  intro- 
duction of  the  probe  will  generally  clear  the  passage;  but 
where  partial  adhesion  of  its  sides  had  taken  place,  I have 
generally  found  a repetition  of  the  operation  necessary. 
The  last  time  I had  occasion  to  pass  the  probe,  I forced 
three  obstructions  in  the  course  of  the  duct. 

The  passage  of  the  probe  along  the  eustachian  tube,  is 
far  from  being  difficult.  The  probe,  if  sligluly  curved. 


OF  THE  HEAD  AND  NECK. 


361 


and  if  conducted  along  the  floor  of  the  nostril,  readily 
enters  the  orifice  of  the  duct,  and  if  not  too  flexible,  it  as 
easily  follows  its  course.  Where  adhesions  require  to  be 
forced,  I employ  a silver  probe,  but  where  mucu3  alone 
has  to  be  removed,  a leaden  wire  about  the  diameter  of  a 
crow  quill  will  be  preferable. 

This  drawing  would  also  illustrate  the  operations  re- 
quired, where  polypi  are  lodged  in  the  nose;  but  as  this 
department  has  already  been  very  completely  treated  by 
Mr  John  Bell,  I refer  to  his  and  other  surgical  works  for 
information  on  that  subject. 


If  there  be  no  stricture  in  the  course  of  the 
nasal  duct,  the  surgeon  will  generally  succeed  in 
conducting  the  probe  from  the  nostril  into  the 
lachrymal  sac,  and  where  the  obstruction  is  slight 
he  may  even  overcome  it.  Where  the  obstruc- 
tion is  firmer,  the  probe  bends  before  the  stric- 
ture will  yield.  Where  this  has  happened,  I 
have  made  a puncture  with  a common  bleeding 
lancet  into  the  lachrymal  sac,  and  through  that 
opening  have  conveyed  a straight  probe  along  the 
duct  into  the  nostril.  In  this  way  a very  firm 
stricture  may  be  forced, — to  keep  the  passage 
pervious  is  the  next  object.  To  accomplish 
this,  I have  introduced  a curved  wire  from  the 
nostril  along  the  nasal  duct,  and  healed  the  punc- 
ture over  it.  This  is  the  same  in  principle  as  the 
French  mode  of  passing  a seton  from  the  sac 
along  the  nasal  duct  into  the  nostril. 

46 


362 


ON  THE  SURGICAL  ANATOMY 


Both  are  equally  effectual,  but  the  seton  is 
liable  to  this  objection,  that  it  lays  the  founda- 
tion of  a fistulous  opening  into  the  lachrymal  sac, 
whereas,  if  the  other  plan  be  adopted  in  the  inci- 
pient stage  of  the  obstruction,  before  the  skin 
covering  the  sac  has  become  inflamed,  the  punc- 
ture will  generally  heal  kindly,  and  without  leav- 
ing any  perceptible  cicatrix.  Where,  however, 
the  operation  is  delayed  till  the  surface  has  become 
diseased,  the  wound  will  be  apt  to  become 
sloughy — in  the  end  it  will  heal  by  granulation, 
leaving  a polished  and  sometimes  puckered  cica- 
trix. We  have,  therefore,  a great  inducement  to 
operate  in  the  early  stage  of  the  obstruction,  and 
much  to  dread  if  we  delay  till  inflammation  has 
taken  place. 

I have  supposed  that  an  operation  will  reallv 
be  useful — that  in  fact  we  have  it  in  our  power 
to  keep  the  nasal  duct  pervious,  securing  thus  a 
passage  for  the  tears  from  the  lachrymal  sac  into 
the  nostril.  Some  doubt  the  truth  of  this,  while 
others  positively  assert,  that  it  is  impracticable  to 
preserve  the  canal  patent  for  any  considerable  time 
after  the  operation.  By  those  who  adopt  the  lat- 
ter sentiment,  the  primary  object  of  operation  is  to 
destroy  the  sac,  and  annihilate  the  function  of  the 
puncta.  This  practice  has,  1 suspect,  been  de- 
rived from  a limited  source  of  observation — it  has, 
perhaps,  originated  from  a supposition  that  the 
nature  of  the  disease  is  similar  m every  case;  but 


OP  THE  HEAD  AND  NECK. 


363 


who  that  has  read  Mr.  Pott’s  very  excellent  tract 
on  fistula  lachrymalis,  and  has  net  been  convinced 
of  the  fallacy  of  this  notion? 

The  disease  is,  indeed,  more  or  less  tractable, 
according  to  its  nature;  sometimes  it  may  be  re- 
moved, and  the  functions  of  tne  sac  and  duct  pre- 
served, at  other  times  these  parts  must  be  sacri- 
ficed. On  this  subject  I shall  not  require  to  en- 
large much,  I would  only  observe,  that  where 
acute  inflammation  has  produced  partial  adhesion 
of  the  sides  of  the  nasal  duct,  the  decided  object 
of  the  surgeon  ought  to  be  to  render  it  pervious 
and  to  retain  the  duct  patent.  Failure  in  accom- 
plishing this,  is  as  frequently  referable  to  the  sur- 
geon as  to  the  disease.  He  never  can  succeed 
if  the  operation  be  undertaken  while  the  duct  is 
acutely  inflamed,  nor  will  he  often  fulfil  his  pur- 
pose if  he  delay  till  ulceration  of  the  sac  has  taken 
place. 

Failure  not  only  arises  from  performing  the 
operation  during  an  improper  stage  of  the 
disease,  but  is  also  occasioned  by  underta- 
king it  in  affections  of  the  duct,  not  remova- 
ble by  operation.  This  is  especially  the  case 
where  the  sac  and  duct  are  thickened  from 
chronic  inflammation.  Where  the  obstruction  is 
dependent  on  this  species  of  disease,  the  inner 
canthus  of  the  eye  is  swelled,  but  is  free  from 
pain.  By  pressing  on  the  tumour,  a clear  fluid 
is  generally  forced  back  by  the  puncta,  but  the 


364 


ON  THE  SURGICAE  ANATOMY 


last  drops  are  sometimes  turbid,  and  in  the  morn- 
ing the  fluid  has  often  a milky  tinge.  Under- 
such  ( ircumstances  the  opening  cannot  be  kept 
pervious — not  even  where  a direct  communication 
has  been  established  between  the  sac  and  the 
nose.  Here,  therefore,  it  will  be  preferable  to 
destroy  the  sac  and  annihilate  the  office  of  the 
puncta.  To  attempt  to  maintain  a pervious 
opening  from  the  sac  into  the  nostril  is  futile; 
any  endeavour  to  do  so  only  teazes  the  patient. 
Where,  however,  the  nasal  duct  is  merely  ob- 
structed by  adhesion  of  its  sides  produced  by 
acute  inflammation,  I can  confidently  affirm,  that 
if  the  duct  be  rendered  pervious  at  a proper 
stage  of  the  disease,  it  may  by  care  be  kept  patent. 

If  we  may  believe  some  authors,  the  conse- 
quences arising  from  the  loss  of  the  lachrymal  ap- 
paratus, are  hardly  deserving  of  notice.  In  their 
opinion,  the  tears  are  evaporated  from  the  surface 
of  the  eye-ball,  as  fast  as  they  are  poured  from 
the  ducts  of  the  lachrymal  gland,  hence  the  puncta 
are  only  called  on  to  absorb  the  superfluous  tears, 
when  the  action  of  the  gland  is  increased  beyond 
its  usual  degree.  If  the  nasal  duct  be  obstructed, 
it  is  at  this  time,  and  at  this  time  only,  that  the 
tears  flow  over  the  cheek.  It  may  here  be  said, 
if  there  be  not  a constant  absorption  of  the  tears 
by  the  puncta,  why  is  obstruction  of  the  nasal  duct 
productive  of  so  much  inconvenience?  This  has 
really  no  force,  since  the  bad  effects  which  are 


OF  THE  HEAD  AND  NECK. 


365 


occasioned  by  obstruction  of  the  nasal  canal,  can 
be  otherwise  accounted  for. 

When  the  nasal  duct  is  strictured,  the  tears 
which  occasionally  are  absorbed  by  the  puncta, 
stagnate  in  the  sac,  and  are  thence  a source  of 
irritation.  The  first  effect  produced,  is  an  alter- 
ation of  the  mucous  secretion  from  the  inner  sur- 
face of  the  sac — it  is  changed  to  a puriform  na- 
ture— presently  the  sac  and  integuments  inflame 
and  ulcerate.  The  unpleasant  effects  then,  which 
result  from  obstruction  of  the  nasal  duct,  do  not 
arise  from  the  mere  interruption  to  the  passage  of 
the  tears,  but  are  occasioned  by  the  irritation  pro- 
duced by  the  detension  of  the  tears  in  the  lachry- 
mal sac.  If,  therefore,  the  sac  be  completely  de- 
stroyed, we  have  reason  to  believe,  that  an  occa- 
sional epiphora  will  alone  incommode  the  patient. 

Tumours  not  unfrequently  form  over  the  situa- 
tion of  the  lachrymal  sac,  and  are  mistaken  for  the 
commencement  of  fistula  lachrymalis.  Even,  how- 
ever, where  these  tumours  were  large,  I bas  e ne- 
ver seen  the  passage  of  the  tears  obstructed,  nor 
have  I ever  experienced  any  difficulty  in  passing 
the  probe  from  the  nose  upwards,  which  I would 
advise  to  be  done  in  all  doubtful  cases. 

Purmanus,  in  his  Chirurgia  Curiosa,  alludes  to 
the  species  of  tumour  I am  at  present  considering, 
and  he  details  a case  in  which  he  cured  the  pa- 
tient. The  tumour,  which  was  very  large,  was 
seated  at  the  inner  canthus  of  the  eye.  It  was 


366 


ON  THE  SURGICAL  ANATOMY 


attached  by  a neck,  and  had  continued  during  two 
years.  Purmanus  applied  a ligature  round  its 
root,  and  renewed  it  six  times.  These  did  not 
completely  destroy  the  tumour,  which  he  at  last 
removed  with  the  knife.  In  this  way  the  whole 
tumour  could  not  be  perfectly  got  away;  a portion 
of  it  was  left  behind,  which  he  destroyed  by  the 
actual  cautery  and  escharotic  powders.  It  was 
two  months  before  the  wound  was  cured  * 

The  tumours  which  form  about  this  part  are 
generally  sacculated,  containing  melicerous-look- 
ing  matter,  sometimes  intermixed  with  hair,  or  at 
other  times  the  cyst  is  filled  with  hydatids. f I 
have  generally  found  it  unnecessary  to  attempt 
the  complete  removal  of  the  cyst  by  the  knife.  By 
cutting  off  the  fore  part  of  the  sac,  and  smearing 
its  posterior  surface  with  either  potassa  or  nitrate 
of  silver,  the  cure  is  readily  enough  completed. 
This,  it  will  be  observed,  is,  in  principle,  the  plan 
adopted  by  Purmanus,  who  only  employed  the  ac- 
tual in  place  of  the  potential  cautery. 

The  application  of  caustic  to  the  inner  surface 
of  that  portion  of  the  sac  which  remains,  is  essen- 
tial, because  in  those  tumours  there  is  a morbid  ac- 
tion of  the  sac,  which  would  perpetuate  the  dis- 
ease. By  many  surgeons  it  has  been  deemed  su- 
perfluous to  do  more  than  merely  evacuate  the 
contents  of  an  incisted  tumour,  but  Mr.  Abernethy 

* Purmanns  Cliirurgia  Curiosa,  page  60. 

f.  Wilmer,  page  60. 


OF  THE  HEAD  AND  NECK. 


367 


has  proved,  th  t in  some  species  more  is  required. 
Those  sacculated  tumours  which  form  about  the 
eye-lids,  are  of  this  description.  I have  seen  se- 
veral cases  where  the  front  of  the  sac  had  been 
sliced  away?  but  I never  saw  an  instance  in  which 
that  practice  was  effectual.  I have  seen  one  when 
exposed,  produce,  in  an  irritable  patient,  a very 
considerable  degree  of  constitutional  affection — a 
derangement  of  the  circulating  and  digestive  or- 
gans, which  one  would  hardly  have  expected  from 
the  exposure  of  so  limited  a surface. 

Where  the  tumour  is  permitted  to  burst,  if  the 
inner  surface  of  the  cyst  be  not  destroyed,  it  soon 
assumes  an  unhealthy  aspect,  discharging  a consi- 
derable quantity  of  fetid  matter,  and  presenting 
an  irregular  ragged  coat,  or  ill  conditioned  fungi 
sprout  from  the  surface  of  the  sac,  which  require 
the  utmost  vigilance  of  the  surgeon  to  destroy.  In 
some  ti  ne  longer  the  parts  around  become  indu- 
rated and  thickened.  Here,  as  much  of  the  dis- 
eased substance  as  possible  is  to  be  removed  by 
the  knife,  and  the  rest  destroyed  by  caustic.  The 
caustic  is  to  be  applied  till  the  surface  assumes  a 
healthy  appearance,  which  will  sometimes  be  after 
the  first,  second,  or  third  application.  It  will 
hardly  be  necessary  for  me  to  put  the  student  on 
his  guard  not  to  apply  too  much  of  the  caustic,  as 
the  lachrymal  sac  might  be  injured,  and  the  cure 
protracted. 


368 


ON  THE  SURGICAL  ANATOMY 


To  enter  into  the  consideration  of  the  anatomy 
of  the  eye,  and  an  enumeration  of  its  various  dis- 
eases, followed  by  a history  of  the  operations  per- 
formed for  their  removal,  would  be  altogether  fo- 
reign to  my  purpose.  I refer  those  who  wish  for 
information  on  these  subjects,  to  the  numerous 
works  on  surgery  in  which  they  are  treated.  I 
cannot,  however,  omit  a few  remarks  respecting 
one  of  the  diseases  of  the  eye.  I allude  to  fungus 
hsematodes,  a disease  which  was  confounded  with 
cancer,  till  Mr.  Wardrop  pointed  out  the  differ- 
ence. His  observations  clearly  establish,  that 
fungus  hsematodes  is  an  affection  more  frequently 
met  with  in  young  than  in  old  people. 

“The  first  appearances  of  the  fungus  hsemato- 
des,  when  it  attacks  the  eye,  are  observable  in  the 
posterior  chamber.  The  pupil  becomes  dilated 
and  immoveable,  and,  instead  of  having  its  natural 
deep  black  colour,  it  has  an  amber,  and,  in  some 
cases,  a greenish  hue;  giving  to  the  eye  very  much 
that  appearance  which  is  observed  in  the  sound 
eye  of  the  sheep,  the  cat,  and  in  many  of  the  lower 
animals.  As  the  progress  of  the  disease  advances, 
the  colour  becomes  more  remarkable,  and  it  is  soon 
discovered  to  be  produced  from  a solid  substance 
which  is  forming  at  the  bottom  of  the  eye,  and 
gradually  approaches  the  cornea. 

“The  surface  of  this  substance  is  generally  rug- 
ged and  unequal,  and  not  unlike  what  may  be  sup- 
posed to  arise  from  a quantity  of  effused  lymph. 


QF  THE  HEAD  AND  NECK.  389 

In  some  cases,  red  vessels  can  be  seen  running 
across  the  opaque  body;  but  these  are  not  the  ves- 
sels which  nourish  it,  but,  the  ramifications  of  the 
central  artery  of  the  retina  lying  above  it.  Dur- 
ing  the  progress  of  the  disease,  the  new  formed 
substance  gradually  fills  up  the  whole  of  the  pos- 
terior chamber;  its  surface  advances,  so  as  to  ar- 
rive at  the  same  plane  with  the  iris,  and  has  the 
appearance  of  an  amber  or  brown  coloured  mass. 
In  this  stage  of  the  disease  I have  known  two  cases 
which  were  mistaken  for  cataracts,  and  in  one  of 
them  an  experienced  surgeon  attempted  to  couch 
it.  When  the  disease  advances  still  further,  the 
form  of  the  eye- ball  begins  to  alter,  acquiring  an 
irregular  knotted  appearance;  at  the  same  time; 
the  sclerotic  coat  loses  its  natural  pearly  white  co- 
lour, and  becomes  of  a dark  blue  or  livid  hue. 
The  tumour,  by  its  continued  growth,  finally  occu- 
pies the  whole  anterior  chamber,  and,  in  some  ca- 
ses, a quantity  of  purulent  matter  collects  between 
it  and  the  cornea.  At  last  the  cornea  ulcerates, 
and  a fungous  tumour  shoots  out  from  the  portion 
of  the  diseased  substance,  contiguous  to  the  ulce* 
rated  cornea;  and,  in  other  cases,  the  tumour 
pushes  itself  through  the  sclerotic  coat. 

“This  fungus  is  very  rapid  in  its  growth,  and 
before  the  disease  arrives  at  a fatal  termination,  it 
often  acquires  a very  great  bulk.  When  it  is 
small,  it  has  a good  deal  the  appearance  of  the 
softer  kinds  of  polypi  which  grow  from  mucous 
47 


370 


ON  THE  SURGICAL  ANATOMY 


membranes.  It  is  generally  of  a dark  red  or  pur- 
ple colour.  Its  surface  is  irregular,  and  often  co- 
vered with  coagulated  blood. 

“The  substance  of  this  fungus  is  very  readily 
torn;  and  when  a portion  of  it  is  separated,  or  if 
it  be  slightly  scratched,  it  bleeds  profusely.  In 
other  cases,  the  tumour  is  of  a firmer  texture,  and 
if,  as  sometimes  happens,  instead  of  coming  through 
the  cornea,  it  bursts  through  the  sclerotic  coat,  it 
then  pushes  before  it  the  tunica  conjunctiva,  and 
thus  derives  a mucous  covering.  When  the  tu- 
mour becomes  very  large,  portions  of  the  most 
prominent  parts  begin  to  lose  their  vitality,  and 
separate  in  sloughs,  which  have  a very  fetid  and 
offensive  smell,  and  are  accompanied  with  the  dis- 
charge of  an  acrid  sanies.”* 

This  is  a description  given  by  Mr.  Wardrop 
of  the  fungus  hsematodes  in  the  eye,  to  the  fidelity 
of  which  I can,  from  my  own  observation,  bear 
testimony  in  every  point,  except  the  sloughing  of 
the  tumour,  which  I have  never  seen  happen,  un- 
less where  the  fungus  was  tightly  girded  by  the 
apperture  through  which  it  had  passed.  As, 
however,  a reference  to  individual  cases  is  more 
valuable  than  general  description,  I shall  tran- 
scribe the  following  very  interesting  case  which 
occurred  to  myself,  and  which  has  been  published 
by  Mr.  Wardrop,  in  his  work  on  Fungus  Hsema- 
todes. 

* Wardrop  oil  Fungus  Hxmatodts,  p.  13. 


OP  THE  HEAD  AND  NECK. 


371 


“The  patient,  Mrs.  Scot,  was  about  forty-one 
years  of  age.  She  had  always  been  of  a delicate 
habit  of  body,  and  of  a sallow  complexion,  but  had 
never  observed  any  affection  of  her  eyes  till  two 
years  and  a half  ago.  About  that  time  she  be- 
gan  to  see  less  distinctly  than  usual  with  her  left 
eye;  and  on  looking  at  that  organ,  a milkiness 
was  seen  behind  the  pupil.  This  opacity  of  the 
lens  gradually  increased  during  four  months,  when 
she  became  completely  blind  of  that  eye.  After 
having  been  blind  for  about  four  months,  the  eye 
became  very  much  inflamed,  without  any  ob- 
vious cause.  By  bleeding  with  leeches,  &c.  the 
inflammation  abated,  but  the  redness  and  pain 
never  entirely  left  the  eye.  From  what  I have 
been  able  to  learn,  the  opacity  of  the  lens  could 
not  be  so  decidedly  ascertained  after  this  attack, 
owing  to  the  turbidity  of  the  contents  of  the  ante- 
rior  chamber. 

“The  further  progress  of  this  case  was  not 
traced  till  within  the  last  six  months.  At  the 
beginning  of  that  period,  a tumour  began  to  pro- 
trude from  the  lower  side  of  the  sclerotic  coat, 
just  behind  the  attachment  of  the  lucid  cornea. 
When  I examined  the  eye  about  four  months  ago, 
it  appeared  that  the  cornea  was  rather  more  pro- 
minent that  usual,  and  I could  neither  distinguish 
with  accuracy  the  iris  nor  crystalline  lens.  The 
appearances  impressed  me  with  the  idea,  that  a 
fungus  was  lodged  behind  the  cornea,  ready  to 


072 


ON  THE  SURGICAL  ANATOM! 


protude  so  soon  as  the  cornea  gave  way;  and 
regard  to  the  tumour  attached  to  the  lower  side 
of  the  sclerotic  coat,  it,  at  that  time,  seemed  to 
contain  a dark-eoloured  transparent  fluid,  which 
I thought  was  a part  of  the  aqueous  humour, 
which  had  escaped  from  the  eye  ball  by  a rup- 
ture of  the  proper  coats  of  that  organ.  This  cyst 
was  about  the  size  of  a musket  ball,  and  was 
formed  by  a distension  of  that  part  of  the  tunica 
conjunctiva  which  covers  the  sclerotic  coat;  and 
over  the  surface  of  the  sae  a number  of  red  ves- 
sels were  seen  running  in  every  direction.  The 
pain  was  intense  and  lancinating;  her  sleep  was 
interrupted;  and  besides  being  affected  with  hys- 
teria and  pain  in  the  hack,  she  was  in  some  degree 
hectic. 

“When  I saw  this  patient,  four  months  after- 
wards, matters  were  in  a much  worse  state  than 
formerly;  her  health  was  now  completely  broken, 
she  had  confirmed  hectic  fever,  and  was  often  at- 
tacked with  paroxysms  of  hysteria.  She  was 
much  reduced  and  exceedingly  weak,  and  had  not 
been  out  of  bed  for  two  months.  On  examining 
the  eye,  it  was  found  that  the  cyst,  which  formerly 
was  not  larger  than  a musket  ball,  had  now  become 
as  large  as  a pigeon’s  egg,  forming  a solid  fungous 
mass,  which  could  with  difficulty  be  raised,  so  as  to 
uncover  the  under  eye-lid.  The  cornea  was  now 
flat,  and  hid  beneath  the  upper  eye-lid,  and  from 
the  body  of  the  large  fungus,  two  small  fungi 


OF  THE  HEAD  AND  NECK, 


873 


protruded.  Towards  the  temporal  angle  of  the 
Under  eye-lid,  there  was  a hard  tumour,  situated 
Underneath  the  integuments,  which  adhered  firmly 
to  the  cheek  bone. 

“As  extirpation  of  the  morbid  parts  afforded 
the  only  hope  of  recovery,  the  patient  was  ex- 
tremely anxious  to  have  the  operation  performed, 
in  which  we  concurred.  Assisted  by  Mr.  War- 
drop,  I performed  the  operation.  As  the  tumour 
exterior  to  the  eye-lid  was  of  considerable  size, 
I followed  the  mode  advised  by  Desault,  which  is 
highly  conducive  to  the  celerity  and  ease  of  ex- 
tirpation. At  the  outer  canthus  of  the  eye,  I 
separated,  by  an  incision,  the  palpebrae,  for 
about  half  an  inch  from  each  other.  I then 
grasped  the  tumour,  and  dissected  back  the  eye- 
lids from  it. 

“As  I wished  to  take  out  all  the  diseased  parts 
in  connexion,  I endeavoured  to  detach  them  from 
the  lower  margin  of  the  orbit,  but  found  to  my 
surprise  and  regret,  that  the  bone  on  which  they 
rested  was  softened  and  black  in  colour.  I there- 
fore gave  Up  this  idea,  and  proceeded  to  detach 
the  eye- ball  from  its  connexion,  with  a common 
scalpel.  While  separating  it  from  the  roof  of  the 
orbit,  I was  cautious,  lest  the  bone  being  there 
soft,  the  point  of  the  knife  might  have  passed 
into  the  brain,  and  I also  kept  the  scalpel  at  some 
distance  from  the  sethmoid  bone,  to  avoid  injury 
of  the  nasal  branch  of  the  ophthalmic  artery. 


374 


ON  THE  SURGICAL  ANATOMY 


“By  the  pressure  employed  in  pulling  forward 
the  morbid  parts,  they  burst,  and  a considerable 
quantityjof  inky  fluid  was  poured  from  the  opening. 
I traced  the  optic  nerve  to  its  exit  from  the  skull, 
and  there  divided  it.  Yet  even  here  its  medul- 
lary substance  was  as  black  as  ink.  I next  ehis- 
selled  away  as  much  as  I could  of  the  diseased 
edge  of  the  orbit,  but  with  little  hope  that  the 
issue  of  the  operation  would  be  favourable.  The 
diseased  state  of  the  optic  nerve,  and  condition  of 
the  bone,  hardly  allowed  any  reasonable  expec- 
tation that  the  patient  would  ultimately  recover. 

“We  now  dressed  the  orbit.  The  first  point  was 
to  check  the  bleeding  from  the  divided  vessels. 
This  was  readily  done  without  employing  a liga- 
ture, which  is  now  seldom  or  never  thought  ne- 
cessary after  extirpation  of  the  eye.  I laid  first 
a very  small  piece  of  lint  on  the  orifice  of  the  ar- 
tery, and  over  this  applied  a plug  of  rolled  up 
lint,  to  which  a strong  thread  was  fixed.  This 
was  made  of  such  a size  as  nearly  to  fill  the  orbit, 
and  it  projected  to  the  level  of  the  palpebrse; 
hence  by  pressing  the  eye-lids  back  on  the  plug, 
it  was  kept  steadily  in  contact  with  the  divided 
vessel,  and  haemorrhage  was  prevented.  By  ha- 
ving a thread  fixed  to  the  plug,  it  could  be  with- 
drawn so  soon  as  suppuration  had  loosened  it  from 
the  part  with  which  it  was  in  contact. 

“This  woman  although  much  reduced  by  a hec- 
tic fever,  and  emaciated  to  a great  degree  at  the 


OF  THE  HEAD  AND  NECK. 


375 


time  of  the  operation  soon  appeared  to  recover — 
she  gained  flesh  and  strength — her  appetite  was 
restored — the  pains  in  her  back  and  loins  left 
her — she  slept  well,  and  was  able  to  walk  about. 
The  orbit  even  discharged  good  pus  in  moderate 
quantity,  and  was  at  last  tilled  up  with  a soft 
substance,  which  although  dark  in  colour,  skinned 
over. 

“ At  this  stage,  when  she  herself  and  her  friends 
considered  her  recovery  certain,  the  weather  be- 
came cold  and  damp;  the  pain  soon  recurred  about 
her  back;  she  lost  her  appetite;  and  was  unable 
to  walk  from  exquisite  pains  in  the  loins.  After 
she  was  confined  to  bed,  she  became  rapidly 
worse.  The  pains  increased  in  severity,  inso- 
much that  she  could  obtain  no  sleep  except  from 
the  use  of  opium.  The  lower  eye-lid  was  pro- 
truded by  an  elastic  fungus,  which  also  began  to 
project  from  between  the  palpebrse. 

‘•The  disease  in  the  orbit  gave  her  no  uneasi- 
ness, her  whole  complaint  being  seated  in  the 
back  and  loins.  The  pain  there  was  so  excru- 
ciating, and  occasionally  so  much  increased 
in  intensity,  that  she  screamed  from  ago- 
ny. She  could  neither  turn  in  bed,  nor  permit 
herself  to  be  turned,  for  on  every  motion  she  felt 
as  if  many  sharp  instruments  were  pushed  into 
her  back.  In  this  deplorable  condition,  she  lin- 
gered for  two  or  three  months;  the  tumour  below 


376 


ON  THE  SURGICAL  ANATOMY 


the  orbit  all  the  while  increasing  in  size,  and  the 
pain  in  the  loins  in  no  degree  remitting. 

“When  I saw  her  three  weeks  before  her  death, 
she  was  a hideous  picture  of  disease;  she  was 
emaciated  to  the  last  degree;  and  the  tumour  be- 
low the  orbit  was  as  large  as  a pullet’s  egg.  Its 
surface  was  unequal,  the  most  prominent  parts 
of  it  were  covered  with  livid  integuments,  and 
the  swelling  conveyed  to  the  fingers  the  impres- 
sion as  if  it  contained  a fluid.  From  between 
the  palpebrse  a very  small  fungus  protruded, 
which  was  covered  with  a coat  of  bloody-looking 
matter.  She  had,  however  little  or  no  pain, 
either  in  the  orbit  or  in  the  head,  and  the  vision 
of  the  other  eye  remained  unimpaired. 

“From  this  time  to  her  death  she  sunk  gradu- 
ally, and  the  tumour  enlarging,  became  more  dis- 
coloured on  its  surface  and  more  irregular,  but 
the  fungus  between  the  eye-lid  did  not  alter. 
About  twenty-four  hours  previous  to  her  death, 
she  became  suddenly  comatose.” 

Dissection  of  the  Eye. 

As  soon  as  possible  after  the  operation  we  made 
a section  of  the  morbid  parts,  and  the  following 
very  accurate  description  of  the  phenomena  was 
drawn  up  by  Mr.  Wardrop:  “When  dividing  the 
eye-ball  and  optic  nerve,  a great  quantity  of  a 
thick  viscid  matter,  having  a very  dark  brown 


€>F  THE  HEAD  AND  NECK. 


3?  1 


colour  covered  the  knife.  The  eye-ball  and  tumour., 
seemed,  at  first  sight,  entirely  composed  of  a simi- 
lar dark  coloured  matter.  This  singular  looking 
substance  was  of  the  consistence  of  thick  oil  paint, 
though  not  so  clammy  nor  oleaginous.  It  soiled  the 
fingers  of  a dark  brown  or  amber  colour.  It  was 
readily  dissolved  in  water,  and  both  Mr.  Burns 
and  I were  struck  with  its  resemblance  to  the  pig- 
ment.um  nigrum;  but  we  were  much  at  a loss  how 
to  account  for  the  formation  of  such  a quantity  of 
that  substance.  I kept  the  eye-ball  in  water  for 
twenty-four  hours,  so  that  a great  quantity  of  the 
black  matter  was  dissolved,  leaving  the  solid  parts 
of  the  mass  more  distinct.  The  cornea  appeared 
sound,  and  the  crystalline  lens  behind  it  was  of  an 
amber  colour. 

“The  sclerotic  coat,  at  that  part  which  corres- 
ponded to  the  malar  portion  of  the  orbit,  was  rup- 
tured by  the  tumour,  and  the  torn  edges  were  se- 
parated about  a quarter  of  an  inch  from  one  ano- 
ther. At  the  same  place  the  sclerotic  coat  was 
split  into  two  layers,  a small  quantity  of  the  dark 
coloured  substance  being  interposed  between  them. 

“I  could  not  trace  any  remains  distinctly  of  the 
iris,  but  the  choroid  coat  appeared  much  more  vas- 
cular than  natural,  and  at  one  part  it  was  five  or 
9ix  times  its  natural  thickness.  At  the  place  where 
the  sclerotic  coat  was  ruptured,  the  choroid  coat 
insensibly  terminated  in  a white  pulpy  substance, 
composing  part  of  the  diseased  mass. 

48 


378 


ON  THE  SURGICAL  ANATOMY 


“The  contents  of  the  eye-ball  were  chiefly  com- 
posed of  a medullary-looking  pulpy  substance,  va- 
riously tinged  in  different  places  by  the  dark 
brown  colouring  matter.  The  tumour  projecting 
beyond  the  sclerotic  coat,  appeared  to  be  com- 
posed of  a similar  structure,  and  from  the  macera- 
tion, numerous  white  strise,  and  in  some  places 
spots,  appeared  throughout  the  substance  of  the 
diseased  mass.  The  tumour,  exterior  to  the  eye- 
ball was  covered  with  a thick  mucous  membrane, 
except  at  the  two  small  prominent  parts  where  it 
had  been  ulcerated,  and  this  covering  had  proba- 
bly been  derived  from  the  tumour  pushing  before 
it  during  its  growth,  the  conjunctiva,  which  lies 
over  the  sclerotic  coat. 

“The  optic  nerve  was  of  its  natural  size,  but  by 
examining  its  section,  it  was  found  that  the  medul- 
lary part  of  it  had  a black  appearance,  exactly  re- 
sembling the  tumour  in  the  eye  ball,  whilst  the 
membrane  was  of  its  natural  colour  and  appa- 
rently healthy.  I could  not  detect  any  remains  of 
the  retina. 

“One  of  the  lymphatic  glands  lying  by  the  side 
of  the  optic  nerve,  was  changed  into  a dark 
coloured  substance.” 

Dissection  of  the  Body. 

The  liver  contained  some  tumours  of  a similar 
texture  and  appearance  with  the  contents  of  the 


OF  THE  HEAD  AND  NECK. 


379 


eye-ball.  There  was  also  a cyst  in  the  substance 
of  the  liver,  filled  with  a great  quantity  of  gru- 
mous-looking  purulent  matter. 

Above  the  kidneys  there  were  similar  tumours 
of  pretty  considerable  size,  and  the  uterus  was 
cartilaginous.  The  urinary  bladder  was  enor- 
mously distended  with  a turbid  bloody-looking 
fluid,  but  otherwise  in  so  far  as  this  viscus  was 
examined,  its  structure  appeared  healthy. 

By  making  a vertical  section  of  the  orbit  and 
fungus  it  contained,  we  found  the  tumour  is  en- 
tirely arising  from  the  antrum  tnaxillare,  which 
was  burst  open  both  above  and  in  front.  The  fun- 
gus also  projected  beyond  the  lower  spongy  bone 
and  investing  membrane  of  the  nose,  into  the  nos- 
tril. The  tumour  proceeding  from  the  antrum, 
was  on  its  outer  surface,  studded  over  with  small 
knobs  of  a dark  livid  colour.  Internally,  this  tu- 
mour was  made  up  of  a soft  substance  of  an  ink  co- 
lour, intersected  by  membranous  slips,  intermixed 
with  a grayish  looking  substance  and  ragged  frag- 
ments of  bone.  The  anterior  wall  of  the  antrum 
was  destroyed  at  the  upper  part,  and  the  floor  of 
the  orbit  was  elevated,  so  as  merely  to  have  the 
periosteum  and  a thin  layer  of  fat  between  it  and 
the  orbitar  plate  of  the  frontal  bone. 

The  fungus  was  exterior  to  the  orbit,  although 
from  the  destruction  of  the  periosteum  attached 
to  the  malar  portion  of  the  orbit,  it  was  allowed 
to  protrude  from  between  the  eye-lids.  This 


380 


ON  THE  SURGICAL  ANATOMY 


portion  of  the  periosteum  was  in  part  destroyed  by 
disease,  and  in  part  in  consequence  of  the  removal 
of  a carious  portion  of  the  bone,  when  the  eye  was 
extirpated. 

With  regard  to  the  optic  nerve,  it  was  expected 
that  its  extremity  would  have  been  joined  and 
connected  with  the  fungus.  Between  them,  how- 
ever, the  periosteum  of  the  floor  of  the  orbit  was 
interposed.  The  nerve  itself  was  of  its  natural 
size,  but  of  a black  colour  where  it  entered  the 
foramen  opticum.  From  this  point  to  near  where 
it  had  been  divided  at  the  extirpation  of  the  eye- 
ball, it  was  in  a similar  state;  the  neurilema  had 
only  a slight  connexion  with  the  diseased  substance 
of  the  nerve.  At  the  bottom  of  the  orbit,  there  was 
considerable  matting  and  induration  of  the  origin 
of  the  muscles*  At  its  termination  the  nerve  formed 
a sharp  point,  and  here  the  coats  of  the  nerve  ad- 
hered to  the  thickened  periosteum  of  the  floor  of 
the  orbit,  which  was  pressed  in  contact  with  it,  by 
the  fungus  from  the  antrum.  The  optic  nerve 
within  the  cranium  was  as  thick  as  the  little  finger, 
and  as  dark  in  colour  as  that  part  of  it  in  the  or- 
bit. The  junction  of  the  nerves  was  so  much  en- 
larged, that  it  formed  a tumour  extending  into  the 
third  ventricle. 

As  from  the  dark  colour  of  the  diseased  parts, 
this  was  a favourable  opportunity  for  ascertaining 
whether  the  optic  nerves  decussate  each  other,  or 
merely  come  in  contact,  I examined  carefully  the 


OF  TflE  HEAD  AND  NECK. 


381 


State  of  these  parts.  I found  the  dark  colour  ex- 
tending much  beyond  the  point  where  the  nerves 
join;  but  this  change  of  colour  was  confined  to  the 
left  side,  or  to  the  nerve  of  the  affected  eye.  On 
the  right  side  the  nerve  was  of  its  natural  size  and 
colour,  and  was  merely  attached  to  the  black  dis- 
eased parts  by  cellular  shreds.  This  dissection, 
therefore,  clearly  proved  that  the  nerves  did  not, 
in  this  individual,  cross  each  other.  I would  be, 
however,  inclined  to  believe,  from  what  I saw,  that 
the  optic  nerves  were  joined  to  each  other  by  in- 
terposed nervous  substance  common  to  both.  The 
left  optic  thalamus  was  of  natural  structure,  but 
about  a third  larger  than  the  opposite  one.  The 
third  and  fourth  ophthalmic  branches  of  the  fifth 
and  sixth  pairs  were  all  healthy. 

In  cases  of  medullary  sarcoma  and  fungus 
hsematodes,  the  disease  is  generally  propagated 
by  absorption,  hence,  in  the  case  just  related,  a 
gland,  in  the  course  of  absorption,  was  found 
contaminated;  but  besides,  there  is  in  some  pa- 
tients, disease  of  parts  seated  at  a distance  from 
each  other,  and  having  no  connexion  which  is  ob- 
vious to  the  anatomist.  The  present  case  furnish- 
es an  example  of  this  fact,  the  eye,  the  antrum, 
and  the  liver,  were  similarly  diseased.  In  each  of 
these  parts  the  black  tumour  existed,  and  in  each 
the  appearance  and  nature  of  the  morbid  parts 
were  alike. 


382  ON  THE  SURGICAL  ANATOMY 

This  case  illustrates  the  formation  of  fungus  in 
the  antrum,  which  is  not  an  unfrequent  occur- 
rence. I have  seen  the  fungus  in  its  incipient 
stage,  when  it  appeared  as  a circumscribed  effu- 
sion of  organized  lymph  from  the  vessels  of  a 
diseased  part  of  the  lining  membrane.  This 
slowly  increases,  and  in  the  advanced  stage  of  the 
disease,  the  tumour  by  its  pressure,  produces 
absorption  of  the  earthy  matter  of  the  bones;  the 
antrum  is  burst  open,  the  lachrymal  duct  is  com- 
pressed, epiphora  is  produced,  ending  sometimes 
in  fistula  lachrymalis; — the  face  is  deformed,  and 
the  lymphatic  glands  about  the  angle  of  the  jaw 
are  contaminated.  The  primary  and  secondary 
tumours  become  incorporated,  the  integuments  ul- 
cerate, fungi  sprout  from  these  openings,  and  the 
discharge  and  hectic  presently  kill  the  patient. 

From  the  nature  of  this  affection,  it  will  appear 
that  the  disease  can  only  be  cured  in  the  early 
stage.  If,  at  that  period,  we  could  destroy  the 
vessels  passing  from  the  membrane  of  the  antrum 
into  the  fungus,  it  would  decay. 

In  one  case  treated  in  London,  Dr.  Brown  in- 
forms me,  that  the  surgeon  made  an  opening  into 
the  antrum,  at  the  spot  where  it  is  generally  per- 
forated. This  was  accomplished  without  difficul- 
ty, since  the  bones  were  so  softened  as  to  permit 
of  their  being  easily  cut  with  a scalpel.  After 
he  had  entered  the  antrum,  he  touched  the  base 
of  the  fungus  with  a heated  wire,  conducted 


OF  THE  HEAD  AND  NECK. 


383 


through  a canula.  By  two  applications  of  the 
actual  cautery,  the  size  of  the  tumour  was  very 
materially  reduced. 

Gariot,  in  his  work  on  the  diseases  of  the 
mouth,  describes  fungus  of  the  antrum,  and  ad- 
vises, that  so  soon  as  the  nature  of  the  disease 
had  been  detected,  we  should  open  the  sinus,  and 
destroy  the  morbid  growth  by  the  actual  cautery. 
“Dan  cette  operation  on  commence  d’abord  par 
detacher  la  joue  de  Pos  maxillaire,  en  incisant 
la  membrane  interne  de  la  bouche;  puis,  apres 
avoir  bien  denude  Pos  des  parties  molles  qui  le 
recouvrent,  on  emporte  avec  un  instrument  en 
forme  de  petite  serpette  toute  la  partie  inferieure 
du  sinus  maxillaire,  on  est  oblige  de  se  servir  du 
ciseau  et  du  maillet  pour  les  parties  qui  offrent 
trop  de  resistance.’7 

Sometimes  the  haemorrhage  is  considerable, 
while  cutting  away  the  base  of  the  antrum,  but 
authors  inform  us,  that  they  have  never  seen  the 
bleeding  resist  the  application  of  the  hot  wire. 

I have  seen  and  dissected  three  cases  of  fun- 
gus in  the  antrum,  but  never  have  seen  any  in- 
stance in  which  an  operation  had  been  attempted; 
I can  readily  believe,  however,  that  if  it  be  suf- 
ficiently early  had  recourse  to,  the  fungus  may  be 
destroyed,  and  the  patient  cured. 

Even  in  a more  advanced  stage  of  the  com- 
plaint, it  has  been  proposed  to  perforate  the  base 
of  the  sinus.  The  object  of  this  practice  can 


J 8 4 


ON  THE  SURGICAL  ANATOMY 


only  be  as  Dr.  Thomson  remarked,  to  allow  the 
fungus  to  form  where  it  will  occasion  least  de- 
formity, and  where  we  can  control  its  growth 
by  ligature,  or  by  the  actual  cautery.  This, 
however,  in  the  generality  of  cases,  will  afford 
only  a temporary  palliation,  since  presently  the 
conglobate  glands  which  have  been  contaminated, 
will,  by  their  progress  to  ulceration  and  the  for- 
mation of  fungus,  destroy  the  patient. 

I saw  a very  fine  illustration  of  this  fact  some 
months  ago: — -the  patient  had  complained,  during 
a length  of  time,  of  deep-seated  pain  in  the 
cheek,  which  came  afterwards  to  be  accompanied 
by  a feeling  of  distention.  Presently  he  breath- 
ed with  constraint  through  the  left  nostril,  where, 
by  examination,  I was  informed,  a pretty  solid 
tumour  had  been  discovered.  It  was  not,  how- 
ever, till  some  weeks  after  that  period  when  I 
saw  the  man;  then  the  fungus  had  widely  dilated 
the  nostril  from  which  it  projected,  so  that  the 
neck  of  the  tumour  where  encircled  by  the  nos- 
tril, was  considerably  thicker  than  the  thumb: 
that  portion  which  lay  exterior  to  the  nostril  was 
expanded,  irregular  on  its  surface,  of  a dark 
purple  colour,  and  distilled  constantly  a thin  fetid 
ichor,  sometimes  mixed  with  venous  blood. 

The  patient,  on  account  of  the  constant  and 
severe  pain  that  had  injured  his  look  and  impair- 
ed his  strength,  was  anxious  to  have  the  diseased 
parts  removed;  but  that  no  one  could  undertake, 


OF  THE  HEAD  AND  NECK. 


385 


since  the  antrum  and  nostril  were  filled  with  fun- 
gus, and  the  glands  behind  the  jaw  contaminated, 
forming  two  tumours  each  larger  than  a turkey’s 
egg,  nearly  in  contact,  exquisitely  painful,  elastic, 
and  irregular  on  the  surface,  but  still  covered  by 
healthy  coloured  skin. 

The  man  was  informed  that  no  operation  would 
now  avail;  that  it  only  remained  for  him  to  abate, 
if  possible,  the  pain  by  the  use  of  opium,  and  to 
avoid,  as  much  as  he  could,  irritation  of  the  tu- 
mours. 

These  remarks,  it  is  evident,  are  only  applica- 
ble to  specific  fungi.  Where  the  morbid  parts 
are  of  the  simple  nature  of  polypi,  they  may, 
even  when  large,  be  destroyed.  Such  must  have 
been  the  description  of  those  tumours  which  have 
been  removed  by  operation,  even  after  they  had, 
by  their  pressure,  caused  absorption  of  the  earthy 
matter  of  the  bones.* 

To  the  very  interesting  case  of  Mrs.  Scott, 
which  illustrates  so  well  the  nature  and  termina- 
tion of  fungus  haematodesf  in  the  orbit  and  an- 
trum, and  which  has  afforded  me  an  opportunity 
of  pointing  out  the  manner  of  extirpating  the  eye 
and  dressing  the  wound,  I shall  add  another  pe- 
culiar case,  operated  on  by  my  brother. 

* See  Appendix,  Note  F. 

t Ur.  Thomson  has  informed  me,  that  this  varietv  of  the  disease,  where 
the  tumour  is  nearl\  black,  had  been  twice  noticed  by  Taller,  and  particu- 
larly described,  although  under  a different  name,  by  Laennee. 

49 


386 


ON  THE  SURGICAL  ANATOMY 


The  patient,  a young  man,  began  three  months 
before  to  observe  a fulness  below  the  superciliary 
ridge  toward  the  temporal  side  of  the  orbit.  For 
some  time  he  felt  little  inconvenience,  but,  at 
last,  to  use  his  own  expression,  he  saw  gray  or 
misty  with  that  eye.  Fifteen  days  after  his  vision 
began  to  be  impaired,  the  tumour  had  considera- 
bly increased,  and  now  when  he  viewed  an  object 
with  both  eyes,  he  saw  double.  Till  within  four- 
teen days,  the  eye-ball  was  not  materially  pro- 
truded from  the  socket.  Much  about  that  time  it 
was  rapidly  forced  out,  and  the  pain,  which  had 
hitherto  been  very  moderate,  was  greatly  aggra- 
vated. 

Eight  days  ago,  the  protruded  eye  became 
highly  inflamed.  On  the  accesion  of  this  inflam- 
mation, vision  was  still  more  obscured,  and  on 
the  following  day  was,  after  the  application  of  a 
cataplasm,  entirely  lost.  Since  that  time  the 
pain  became  excessive  and  stinging,  darting  back 
into  the  head,  every  part  of  which  felt  as  if 
bruised.  The  tumour  in  the  mean  time  increas- 
ed with  amazing  rapidity;  the  protruded  eye- 
ball was  of  a dusky  red  colour,  and  the  tunica  con- 
junctiva covering  it  was  thickened,  had  a gela- 
tinous appearance,  and,  in  spots,  was  patched  with 
lymphatic  exudation.  Behind  the  lucid  cornea, 
which  was  now  very  opaque,  a drop  of  purulent 
matter  was  lodged. 


OF  THE  HEAD  AND  NECK. 


387 


To  palliate  the  severity  of  the  pain,  a punc- 
ture was  made  through  the  cornea,  but  a small 
quantity  of  pus  only  was  evacuated.  The  open- 
ing was  soon  obstructed  by  a protrusion  of  the 
iris,  which  was  coated  over  with  lymph. 

This  case  was  viewed  as  a disease  of  the 
lachrymal  gland,  accompanied  with  a morbid 
state  of  the  eye  ball,  produced  by  the  pressure 
of  the  enlarged  gland.  On  this  idea  it  might 
have  been  supposed  unnecessary  to  remove  the 
eye  along  with  the  gland;  but  as  vision  was  now 
irretrievably  lost,  and  as  there  was  a possibility 
that  the  disease  might  be  of  a specific  nature,  it 
was  considered  safest  to  remove  it.  The  opera- 
tion was  performed  by  my  brother  in  the  usual 
way. 

After  the  operation  the  patient  never  felt  com- 
fortable; the  pain  in  his  head  continued,  the  pal- 
pebrse  sloughed,  intense  pains  became  fixed  about 
the  joints,  tumours  seemingly  arising  from  the 
bone,  formed  on  each  side  of  the  head  and  on 
each  thigh;  the  right  lachrymal  gland  began  to 
enlarge,  pushing  out  the  eye  as  on  the  opposite 
side;  he  gradually  lost  the  power  of  his  lower  ex- 
tremities, and  the  capability  of  discharging  his 
urine;  sloughs  formed  on  the  buttocks,  his  appe- 
tite failed,  his  mind  and  body  were  equally  un- 
settled, so  that  at  length  he  died  completely 
exhausted. 


388 


ON  THE  SURGICAL  ANATOMY 


Dissection  of  the  eye-ball  and  lachrymal  gland. 

The  vitreous  humour  having,  by  the  pressure, 
escaped  during  the  operation,  the  eye  was  col- 
lapsed, when  sent  to  me  for  examination.  The 
tunica  conjunctiva  was  fleshy  and  rough  on  its 
outer  surface,  and  a considerable  quantity  of 
transparent  intersticial  fluid  was  effused  into  the 
cellular  membrane,  connecting  it  to  the  adjacent 
parts.  It  was  this  deposition  which  occasioned 
the  gelatinous  look  of  the  conjunctiva,  previous 
to  the  operation.  By  alcohol  this  fluid  was  co- 
agulated. 

At  the  centre  the  cornea  was  very  thin,  but 
transparent;  towards  the  circumference  it  was 
thickened,  and  of  a dirty  greenish  yellow  colour. 
The  sclerotic  coat,  along  its  whole  extent,  was 
healthy.  The  choroid  coat  was  of  a very  deep  red 
colour,  and  entirely  without  pigmentum  nigrum. 
At  the  ligamentum  ciliare  it  terminated  in  a thick 
ragged  edge,  formed  by  the  agglutination  of  the 
corpus  ciliare,  and  the  thickened  and  lacerated 
iris.  By  the  most  careful  examination,  before 
and  alter  immersion  in  alcohol,  I could  discover 
no  vestige  of  the  pulpy  part  of  the  retina.  A 
delicate  dark  red  coloured  membrane,  resembling- 
in  texture  the  tunica  arachnoides,  lay  in  the  situ- 
ation ot  the  retina.  The  optic  nerve,  exterior 
to  the  eye  was  healthy. 


OF  THE  HEAD  AND  NECK.  389 

The  lachrymal  gland,  as  large  as  a hen’s  egg, 
was  flattened,  defined  by  a capsule,  was  without 
trace  of  division  into  lobules,  in  density  and 
smoothness  it  resembled  cartilage,  and  it  was  of 
a pale  straw  colour,  inclining  slightly,  in  some 
lights,  to  a greenish  tinge. 


DESCRIPTION  OF  PLATE  VIII — Fig.  2. 

This  Figure  is  intended  to  illustrate  the  external  ap- 
pearance of  the  diseased  lachrymal  gland,  just  described. 
The  tumour  has  pushed  the  eye  from  its  socket,  and  pro- 
truded the  upper  palpebrse,  disfiguring  the  face.  The  lucid 
cornea  is  traversed,  by  the  incision  made  the  day  before 
the  parts  were  extirpated,  for  the  purpose  of  evacuating  a 
little  purulent  matter  which  was  contained  in  the  anterior 
chamber  of  the  eye.  See  page  333. 


Dissection  of  the  Body. 

The  orbit  from  which  the  eye  had  been  extir- 
pated, was  filled  with  a substance  resembling  in 
texture  and  colour,  the  diseased  lachrymal  gland. 
It  wanted,  however,  the  uniform  smoothness  of 
the  gland.  It  was  fibrous,  and  the  fibres  ran  ac- 
cording to  the  direction  of  the  recti  muscles.  By 
removing  what  remained  of  the  upper  eye-lid  and 
the  skin  covering  the  eye-brow,  a tumour  was 
brought  into  view,  resembling  in  texture  the  con- 


390 


ON  THE  SURGICAL  ANATOMY 


tents  of  the  orbit.  It  was  attached  to  the  super- 
ciliary ridge  of  the  frontal  bone,  which,  at  the 
point  of  attachment,  was  rough  and  rather  swell- 
ed. The  frontal  sinuses  were  occupied  by  tu- 
mours of  a similar  texture,  which  were  chiefly 
connected  with  the  investing  membrane  of  the  si- 
nuses. Even  where  the  tumours  were  not  attach- 
ed, the  lining  membrane  of  the  sinuses  was  thick- 
ened and  altered  in  their  appearance.  In  every 
part  they  had  the  greenish  yellow  colour  of  the 
contents  of  the  orbit,  diversified  by  spots  of  a 
florid  colour,  produced  by  the  ramification  of 
blood  vessels  filled  with  arterial  blood. 

The  sethmoidal  and  sphenoidal  sinuses,  and 
many  of  the  cells  connected  with  the  nose,  were 
found  containing  similar  tumours,  and  much  of 
the  Schneiderian  membrane  had  assumed  the  same 
morbid  appearance  and  colour,  but  on  both  sides 
the  investing  membrane  of  the  antrum  maxillare 
was  free  from  disease. 

In  the  opposite  orbit,  the  lachrymal  gland  w’as 
found  precisely  similar  in  texture  to  what  it  had 
been  on  the  other  side,  and  the  periosteum  also, 
on  which  the  gland  rested,  was  changed  in  its 
organization.  The  eye- ball,  the  fat,  the  muscles, 
and  the  nerves,  were  still  free  from  disease. 

In  various  spots  the  dura  mater  was  thickened, 
and  presented  the  same  characters  as  the  other 
morbid  parts,  and  opposite  to  each  of  these  points, 
the  internal  table  of  the  skull  was  rough  and 


OP  THE  HEAD  AND  NECK. 


391 


more  porous  than  usual.  Two  similar  tumours 
were  attached  to  the  other  surface  of  the  skull. 

The  disease  in  this  case  was  surely  of  a specific 
nature.  It  was  widely  extended,  and  as  intracta- 
ble as  fungus  haematodes  Yet  few,  from  the  or- 
ganization of  the  diseased  parts,  will  be  inclined 
to  believe  the  disease  to  have  been  fungus  haema- 
todes. It  presented  none  of  the  characters  of 
that  disease.  The  complaint  seemed  to  me  to 
have  been  one  sui  generis.  The  series  of  parts 
affected,  and  the  mode  of  propagation  of  the  dis- 
ease, were  different  from  what  is  generally  met 
with  in  either  fungus  haematodes  or  medullary 
sarcoma.  In  these  the  neighbouring  parts  are 
commonly  contaminated,  either  by  actual  contact, 
or  by  absorption;  or  in  a less  obvious  way  some 
of  the  internal  viscera  are  diseased.  But  I have 
never  heard  of  an  instance,  in  which  the  tex- 
tures affected  in  this  patient,  were  the  seat  of 
medullary  sarcoma  or  fungus  haematodes;  neither 
have  I known  any  instance,  in  which  the  latter 
disease  had  advanced  so  far,  without  producing 
contamination  of  the  conglobate  glands  in  the 
eourse  of  absorption. 

In  this  disease,  however,  the  conglobate  glands 
which  received  the  lymphatics  from  the  morbid 
parts  were  unaffected.  The  disease  was  exten- 
ded to  parts  dissimilar  in  texture,  and  in  so  far 
as  sve  know,  entirely  unconnected  by  absorbents. 
The  dura  mater,  the  lining  membrane  of  the 


392  ON  THE  SURGICAL  ANATOMY 

nasal  sinuses,  the  contents  of  the  orbit  from 
which  the  eye  and  lachrymal  gland  had  been  ex- 
tirpated, and  the  lachrymal  gland  on  the  op- 
posite  side,  all  presented  unequivocal  features  of 
the  disease.  These  could  not  be  contaminated 
by  either  absorption  or  continuity;  but  how  the 
disease  was  propagated,  or  what  its  nature  was, 
are  points  on  which  we  must  confess  our  igno- 
rance. 

Nevertheless,  I would  not  have  it  supposed  that 
the  case  is  without  value.  In  its  progress  and 
termination  it  is  highly  interesting;  never  was  an 
operation  undertaken  with  greater  probability  of 
success,  and  never  were  diseased  parts,  to  appear- 
ance, more  completely  removed,  than  in  the  pre- 
sent instance.  Yet  it  has  been  seen,  that  from  the 
first  to  the  last  day  after  the  operation,  the  symp- 
toms were  untoward.  There  was  not,  as  gene- 
rally there  is  after  the  removal  of  carcinomatous  or 
spongoid  tumours,  even  a temporary  suspension  of 
the  complaint;  the  operation  only  seemed  to  have 
added  force  to  the  disease  and  accelerated  its  pro- 
gress. 

While  the  external  carotid  artery  is  deeply  im- 
bedded in  the  substance  of  the  parotid  gland,  it 
sends  off  the  large  internal  maxillary  artery,  which 
instantly  dives  behind  the  ascending  plate  of  the 
lower  jaw  bone,  and  protected  by  it,  sends  its 
branches  in  safety  to  all  the  deep-seated  parts 
about  the  face. 


OF  THE  HEAD  AND  NECK. 


393 


From  the  point  where  the  internal  maxillary 
artery  is  sent  off  the  temporal  artery  becomes 
more  superficial,  till  at  last  it  passes  over  the  zy- 
gomatic process  of  the  temporal  bone,  to  be  im- 
bedded in  the  cellular  substance  which  covers 
the  aponeurosis  of  the  temporal  muscle.  Here 
it  is  quite  superficial,  and  here  the  surgeon  gen- 
erally opens  that  vessel.  I know  no  operation 
simpler,  nor  at  the  same  time,  oftener  imper- 
fectly executed,  than  arteriotomy.  The  causes 
of  failure  are  worth  the  investigating,  because 
when  understood  they  are  easily  avoided.  From 
what  I have  observed  in  many  instances,  I am 
fully  convinced  that  the  surgeon  may  be  foiled  in 
two  ways.  If  he  cut  the  artery  completely  across, 
he  will  only  obtain  a small  quantity  of  blood, 
and  if  he  attempt  to  open  the  vessel  while  it  is 
in  a state  of  contraction,  the  orifice  made  by  the 
lancet  can  neither  be  fair  nor  large.  Let  these 
two  facts  be  kept  in  remembrance,  and  disap- 
pointment will  seldom  be  experienced  in  perform- 
ing this  operation. 

In  opening  the  temporal  artery,  I always  make 
firm  pressure  with  the  fore  finger  of  the  left  hand 
on  the  artery,  a little  higher  than  the  point  where 
I intend  to  open  it,  and  with  the  thumb  of  the 
same  hand  a little  lower.  In  this  way  I keep  the 
canal  of  the  vessel  distended,  by  intercepting  a 
quantity  of  blood.  Then  with  a scalpel  I make 
an  incision  about  half  an  inch  in  length,  down  to 
50 


394 


ON  THE  SURGICAL  ANATOMY 


the  artery,  which  I next  puncture  longitudinally 
with  a lancet.  Having  removed  the  pressure 
with  the  thumb,  eight  or  ten  ounces  of  tdood  gen- 
erally flow  from  the  artery.  Then  the  bleeding 
begins  to  flag,  and  may  be  fully  checked,  either 
by  cutting  the  artery  across,  or  by  applying  a 
small  compress  over  it,  retained  by  a proper 
bandage.* 

I have  heard  some  complain,  that  when  they 
trusted  to  the  first  plan,  the  haemorrhage  was 
sometimes  renewed.  This  generally  depends  on 
the  artery  having  been  divided  at  some  distance 
from  the  lower  angle  of  the  wound.  I do  not 
remember  ever  to  have  seen  the  bleeding  return, 
where  the  vessel  had  been  fairly  cut  across  at  the 
lowest  point  of  the  wound,  but  even  if  it  did, 
touching  it  with  the  oil  of  turpentine  would  in- 
stantly check  the  effusion  of  blood. 

In  mania,  where  it  is  necessary  to  detract  blood, 
I uniformly  open  the  temporal  artery,  because 
where  a vein  in  the  arm  has  been  punctured  in  an 
unruly  patient,  the  compress  is  apt  to  slip  aside, 
and  blood  be  lost.  After  division  of  the  tempo- 
ral artery  in  a high  patient,  I have  repeatedly 
trusted  the  person  with  merely  a slip  of  adhesive 
plaster  over  the  wound,  and  have  seldom  been 
troubled  with  a return  of  haemorrhage. 

* The  editor’s  experience  on  the  subject  of  securing  the  patient  against 
haemorrhage  after  the  operation  of  artenolomy  has  been  executed,  would 
induce  him  to  recommend  tying  the  artery  in  preference  to  either  of 
the  plans  stated  in  the  text. — Ed. 


OF  THE  HEAD  AND  NECK. 


395 


Some  way  above  the  zygoma,  the  temporal  ar- 
tery, like  the  other  arteries  of  the  head,  becomes 
imbedded  in  the  tough  and  firm  substance  of  the 
scalp.  This  gives  a peculiarity  of  character  to 
wounds  of  the  vessels  of  the  head.  When  an  ar- 
tery is  wounded  where  lodged  among  loose  and 
fatty  cellular  membrane,  if  external  bleeding  be 
prevented,  the  blood  is  injected  among  the  cellu- 
lar meshes,  forming  a dense  dark  black  placenta- 
looking mass,  from  innumerable  pores  of  which 
blood  issues  as  from  a sponge.  Where,  however, 
the  artery  is  running  among  muscles,  or  is  imbed- 
ded in  the  scalp,  the  blood  is  collected,  forming  a 
circumscribed  effusion,  which  is  soon  defined  by 
a lymphatic  exudation,  and  under  these  circum- 
stances, a trumpet- like  process  of  coagulating 
lymph  is  sometimes  attached  to  the  orifice  of 
the  vessel  through  which  the  blood  has  been 
poured  out.  This  has  been  observed  in  the  tho- 
rax by  Morgagni;*  in  wounded  ischiatic  artery 
it  has  been  met  with  by  Dr.  Jeffray;f  and  I have 
had  an  opportunity  of  seeing  it  in  a young  wo- 
man whose  occipital  artery  had  been  injured. 
In  a street  quarrel  she  received  a blow  on  the 
occiput,  inflicted  by  a large  angular  stone.  By 
the  injury  she  was  stunned,  so  that  she  fell  down 
and  remained  in  a state  of  insensibility  for  a 
length  of  time,  during  which  blood  continued  to 


* Morgagni,  vol.  i.  letter  17,  art.  14. 
+ Bell’s  Principles  of  Surgery,  vol.  i. 


39G  ON  THE  SURGICAL  ANATOMY 

flow  from  the  wound.  When  discovered,  further 
bleeding  was  prevented  by  a compress  and  roller. 

Some  days  after  the  accident,  my  brother  was 
desired  to  visit  the  patient.  The  integuments 
round  the  wound  were  elevated  into  a conical  tu- 
mour, perforated  at  its  apex  by  the  injury  done 
by  the  sharp  corner  of  the  stone.  The  aperture 
was  ragged,  and  the  surrounding  skin  was  dark- 
eoloured.  The  tumour  neither  pulsated  nor  was 
diminished  by  pressure,  but  it  evidently  contain- 
ed blood,  which  was  prevented  from  escaping  by 
a large  coagulum  which  plugged  the  orifice. 

The  patient,  although  warned  of  the  risk, 
would  not  consent  to  the  tumour  being  opened; 
she  followed  her  own  inclinations  in  regard  even 
to  dressing,  which  was  so  clumsily  applied,  that 
the  coagulum  slipped  from  the  wound  during  the 
night,  a profuse  bleeding  followed  its  removal, 
she  fainted,  and  during  the  continuance  of  syn- 
cope, a new  coagulum  formed.  This  kept  its 
place  for  a few  days,  then  came  away,  and  as  be- 
fore, its  removal  was  followed  by  a considerable 
loss  of  blood.  This  discharge  and  reprodtietion 
of  the  coagulum  and  consequent  bleeding,  were 
continued  during  two  weeks,  before  ber  consent 
could  be  obtained  to  cut  into  the  tumour  and 
secure  the  artery.  At  last  the  cyst  was  laid  fully 
open,  the  clotted  blood  cleared  away,  after  which, 
the  florid  jet  of  blood  was  seen  issuing  from  a 
trumpet-like  orifice;  languid  indeed,  since  from 


OF  THE  HEAD  AND  NECK. 


39 


the  frequent  repetition  of  haemorrhage,  she  was 
much  reduced,  and  fainted  on  every  trivial  exer- 
tion. The  pedicle  of  this  trumpet-like  expansion 
was  included  in  a ligature,  but  it  wanted  strength 
to  bear  the  necessary  tightening  of  the  thread.  It 
tore  across,  the  bleeding  was  renewed,  but  was 
finally  suppressed  by  passing  a ligature  round 
the  artery  itself. 

This  case  occurred  before  Mr.  John  Bell’s 
Principles  of  Surgery  were  published,  therefore 
my  brother  was  not  at  first  aware,  that  this  lym- 
phatic expansion  was  neither  possessed  of  sufficient 
strength  to  resist  the  ligature,  nor  organization  to 
effect  adhesion.  It  must,  of  course,  be  brushed 
off  from  the  vessel  with  the  handle  of  the  scalpel, 
and  the  extremity  of  the  artery  itself  included  in 
the  ligature. 


OBSERVATIONS 


ON  THE 

STRUCTURE  OF  THE  NECK 


IN  THE 

YOUNG  SUBJECT. 


In  some  points,  the  differences  between  the 
relative  situation  of  the  various  parts  about  the 
neck,  in  the  child  and  adult,  are  strongly  marked, 
and  of  considerable  importance. 

In  a child  aged  about  twelve  months,  the  space 
from  the  chin  to  the  sternum  measures,  when 
the  base  of  the  skull  is  placed  parallel  to  the  ho- 
rizon, three  finger-breadths.  At  this  age  the 
os-hyoides  is  placed  on  the  same  plane  with  the 
inferior  margin  of  the  lower  jaw-bone,  and  at  the 
distance  of  two  finger- breadths  behind  the  chin, 
and  as  yet  no  projections  are  formed  by  the  car- 
tilages of  the  larynx.  One  finger  covers  the 
space  from  the  os  hyoides  to  the  lower  margin  of 
the  cricoid  cartilage;  then,  allowing  half  the 
breadth  of  the  finger  for  the  thyroid  gland 


400 


ON  THE  SURGICAL  ANATOMY 


itself,  which  is  broader  in  proportion  than  in  the 
adult,  there  will  remain,  for  the  distance  between 
the  thyroid  gland  and  the  sternum,  a finger- 
breadth  and  a half. 

When  the  head  is  turned  back,  five  fingers 
can  be  introduced  between  the  chin  and  the 
chest,  and  four  of  these  can  be  laid  between  the 
os-hyoides  and  the  sternum.  By  the  stretching 
of  the  membrane  between  the  os  hyoides  and  thy- 
roid cartilage,  half  a finger-breadth  is  gained  on 
the  distance  between  that  bone  and  the  lower 
margin  of  the  cricoid  cartilage;  then  deducting, 
as  formerly,  half  a finger- breadth  lor  the  thyroid 
gland,  there  are  two  finger- breadths  left  between 
that  gland  and  the  sternum. 

Generally,  at  this  early  period  of  life,  the  thy- 
mus gland  mounts  about  half  an  inch  above  the 
level  of  the  sternum.  It  is  interposed  between 
the  sternum  and  the  left  subclavian  vein  and  arte- 
ria  innominata.  The  upper  margin  of  the  former 
vessel  is  p.-.rallel  to  the  highest  point  of  the  ster- 
num, while  its  lower  crosses  the  origins  of  the 
arteries  rising  from  the  arch  of  the  aorta.  The 
arteria  innominata  seldom  turns  to  the  side  of  the 
trachea,  lower  than  a quarter  or  half  an  inch 
above  the  chest. 

The  sterno  mastoid  muscle  and  the  omo-hyoi- 
deus  decussate  each  other  two  finger-breadths 
above  the  clavicle,  and  three  below  the  angle  of 
the  jaw.  As  in  the  adult,  the  common  carotid 


OF  THE  HEAD  AND  NECK. 


401 


artery  lies  just  behind  the  point  of  intersection 
of  these  muscles.  The  division  of  the  carotid 
into  its  external  and  internal  trunks,  takes  place 
a finger-breadth  above  the  crossing  of  the  omo- 
hyoideus  and  the  sterno-mastoid  muscles,  and 
consequently  two  finger-breadths  below  the  angle 
of  the  jaw,  nearly  opposite  to  the  upper  margin 
of  the  thyroid  cartilage.  The  division,  therefore, 
of  the  carotid  takes  place,  in  regard  to  the  la- 
rynx, at  precisely  the  same  point  in  the  young 
and  old  subject.  Yet,  when  we  view  the  rela- 
tion of  the  bifurcation  of  the  carotid  to  the  jaw, 
in  the  child  and  adult,  we  find  a wonderful  dif- 
ference— a difference  entirely  dependent  on  the 
non-evolution  of  the  alveolar  processes,  and  of 
the  teeth.  When  these  are  evolved,  the  margin 
of  the  jaw  descends,  so  as  to  cover,  in  a great  de- 
gree, several  of  the  arteries  exposed  in  the  young 
subject. 

In  the  child,  the  superior  thyroid,  the  lingual, 
the  labial,  the  inferior  pharyngeal,  and  the  occi- 
pital arteries,  generally  arise  from  the  external 
carotid  lower  than  the  digastric  muscle,  and  the 
latter  vessel  is  proportionably  nearer  to  the  portio= 
dura  than  in  the  adult. 

In  summing  up  the  differences  in  the  relation 
of  the  parts  between  the  chin  and  the  chest,  in 
the  adult  and  young  subject,  we  are  first  led, 
in  the  latter,  to  notice  the  great  distance  between 
the  bifurcation  of  the  carotid  and  the  angle  of  the 
51 


402  ON  THE  SURGICAL  ANATOMY 

jaw,  the  exposure  of  the  primary  branches  of  the 
arteries,  and  the  immense  space  between  the  jaw 
and  the  point  of  decussation  of  the  omo-hyoideus 
and  the  sterno-mastoid  muscle. 

In  the  adult,  when  the  head  is  turned  back, 
the  space  from  the  chin  to  the  sternum  measures 
twelve  finger-breadths,  and  the  intersection  of 
these  muscles  is  placed  four  finger-breadths  be- 
low the  angle  of  the  jaw.  In  the  child,  whose 
head  is  turned  back,  we  can  only  place  five  fin- 
gers between  the  chin  and  the  sternum,  yet  here 
the  decussation  of  the  omo-hyoideus  and  the 
sterno-mastoid,  is  situated  three  finger-breadths 
below  the  jaw.  The  reason  of  this  difference  has 
already  been  pointed  out.  It  has  been  shewn, 
that  it  is  occasioned  by  the  shortness  of  the  as- 
cending branch  of  the  lower  jaw-bone,  and  by  the 
narrowness  of  both  maxillae,  previous  to  the  for- 
mation of  the  alveolar  processes.  About  the  se- 
venth year  the  permanent  teeth  begin  to  protrude, 
now  the  jaws  deepen,  the  angle  is  carried  back- 
ward, to  make  way  for  the  evolution  of  the  grind- 
ers, and  at  the  same  time  the  ascending  branch  of 
the  maxilla  elongates;  the  parts  about  the  neck 
assume  more  and  more  of  the  adult  arrangement. 

In  comparing  the  young  subject  with  the  adult, 
one  is  naturally  struck  with  the  difference  in  the 
capacity  of  the  larynx.  Neither  the  external 
size,  nor  the  canal  of  the  trachea,  is,  in  the  child, 
proportioned  to  the  body.  On  this  subject,  Rich- 


OF  THE  HEAD  AND  NECK. 


403 


erand  has  written  a very  ingenious  and  useful 
memoir,  in  which  the  facts  are  so  clearly  stated, 
and  the  inferences  so  just,  that  I prefer  transeri- 
bing  his  own  words: 

“Un  jeune  homme  age  de  quatorze  ans,  encore 
impubere,  mourut  a l’hospice  de  la  charite.  En 
ouvrant  le  larynx,  je  fus  surpris  de  sa  pititesse, 
et  sur  tout  du  peu  d’entendue  de  la  glotte,  qui 
n’avoit  que  cinq  lignes  dans  son  diametre  antero- 
posterieur,  et  une  ligne  et  demie  environ  dans  le 
transversal,  a l’endroit  oq  elle  a le  plus  de  largeur. 
Une  observation  qui  ne  doit  point  etre  negligee, 
c’est  que  la  taille  de  Findividu  etoit  elevee,  mais 
que  le  developpement  de  ses  parties  genitales  etoit 
aussi  peu  avance  que  celui  de  Forgane  vocal. 
J’ai  r^itere  la  meme  observation  sur  des  sujets 
plus  eloignes  de  l’epoque  de  la  puberte;  j’ai  eten- 
du  mes  recherches  a ceux  qui  Favoient  depassee, 
et  j’ai  obtenu  pour  resultat  gen  ral;  qu’entre  le 
larynx  et  la  glotte  d’un  enfant  age  de  trois  ou  de 
douze  annees,  les  differences  de  grandeur  sont 
tres-peu  remarquables,  presqu’imperceptibles,  et 
ne  peuvent  point  se  mesure  par  la  stature  des 
individus. 

“Qu’a  l’epoque  de  la  puberte,  Forgane  de  la 
voix  grossit  rapidement,  et  qu’en  moins  d’une 
ann6e  l’ouverture  de  la  glotte  augmente  dans  la 
proportion  de  5-10  qu’ainsi  son  etendue  est  dou- 
blie,  soit  sous  la  rapport  de  sa  longeur,  soit  dans 
le  sens  de  sa  largeur. 


404  ON  THE  SURGICAL.  ANATOMY 

^Que  ces  changemens  sont  raoins  prononces 
ehez  la  femme,  dont  la  glotte  ne  s’aggrandit  guere 
que  dans  la  proportion  de  5-7;  qu’ainsi,  sous  ce 
rapport,  elle  se  rapproche  de  Penfant,  comme  le 
timbre  de  sa  voix  Pavoit  deja  fait  presumer. 

“Les  differences  de  grandeur  de  la  glotte  ren- 
dent  raison  du  danger  qui,  dans  les  enfans,  ac- 
compagne  Pangine  laryngee;  soit  en  effet  une 
ouverture  d’une  ligne  et  demie  de  largeur,  dont 
les  bords  se  couverent  d?une  lame  albumineuse  de 
trois  quarts  de  ligne  d’epaisseur,  Pouverture  sera 
entierement  boucb.ee.  Elle  seroit  seulement  re- 
trecie;  si  sa  largeur  etoit  double;  un  espace  suf- 
fissant  resteroit  libre  pour  le  passage  de  Pair. 
Cette  supposition,  dont  je  me  suis  aide  pour  me 
rendre  plus  intelligible,  n’est  que  Pexpression  de 
la  verite,  puis  que  Pinspection  anatomique  demon- 
tre  que  la  glotte  a dans  les  adultes  une  grandeur 
double  de  celle  qiPelle  presente  dans  les  individus 
impuberes.”* 

A change  is  not  only  produced  on  the  voice, 
by  the  evolution  of  the  larynx,  but  the  relative 
position  of  some  of  those  parts  in  the  vicinity 
of  the  larynx  is  altered.  Richerand  has  confined 
his  whole  attention  to  the  changes  produced 
in  the  economy  of  the  larynx  itself;  but  these 
changes,  although  highly  important,  are  not  the 
only  effects  springing  from  the  evolution  of  the 

*Recherches  sur  la  Grandeur  de  la  Glotte,  par  A.  Richerand.  Me- 
jnoires  de  la  Societe  Medicale  d’Emulation,  tome  iii.  p.  32(1. 


OF  THE  HEAD  AND  NECK.  405 

organ  of  voice,  which  interest  the  practitioner. 
We  must  now  study  the  variations  in  the  rela- 
tive distance  between  the  lower  edge  of  the  thy- 
roid gland,  and  the  upper  edge  of  the  sternum. 
When  we  compare  the  space  between  these  two 
points  in  a child  of  two  years  of  age,  with  the 
space  between  the  same  points  in  the  adult,  we 
find  that  the  distance  is  equally  great  in  both 
subjects.  And  I have  uniformly  found,  in  a 
subject  just  before  the  age  of  puberty,  an  actual 
measurement  of  from  a quarter  to  half  an  inch 
more  between  the  sternum  and  the  thyroid  gland, 
than  in  the  adult.  The  cause  of  these  peculi- 
arities is  easily  explained;  it  has  already  been 
stated,  that  in  the  early  period  of  life  the  larynx 
is  diminutive,  in  proportion  to  the  other  parts 
of  the  body,  hence  it  follows,  in  childhood  that 
the  trachea  must  be  proportionally  longer  than 
in  the  adult. 

The  position  of  the  cricoid  cartilage  regulates 
the  situation  of  the  thyroid  gland,  consequently 
in  children,  in  whom  this  cartilage  is  relatively 
high  placed  in  the  neck,  the  space  between  the 
lower  border  of  that  gland  and  the  sternum  must 
be  large.  As  the  larynx,  however,  begins,  at  the 
age  of  puberty,  to  be  evolved,  the  crocoid  carti- 
lage is  depressed,  the  thyroid  gland  descends 
along  with  it,  and  the  distance  between  that  gland 
and  the  chest  is  reduced.  This  fact  will  explain 
the  reason  why,  by  bending  back  the  head  in  the 


406 


on  the  Surgical  anatomy 


adult,  the  measurement  is  chiefly  increased  be- 
tween the  chin  and  the  thyroid  gland;  and  why, 
before  the  evolution  of  the  larynx,  the  space  is 
principally  increased,  by  bending  back  the  head, 
between  the  gland  and  the  chest. 

From  these  facts  it  may  fairly  be  inferred,  that 
in  children,  in  whom  the  operation  of  tracheotomy 
will  chiefly  be  required,  it  may  be  equally  safely 
performed  as  in  the  adult.  Having  mentioned  the 
operation  of  bronchotomy,  it  may  not  be  superflu- 
ous to  enter  a little  into  the  consideration  of  the 
causes  rendering  it  necessary,  and  into  an  inquiry 
concerning  the  way  in  which  the  operation  has 
been  performed. 

Formerly  this  operation  was  recommended  on 
more  trivial  occasions  than  at  present.  Some  ad- 
vising it  to  be  resorted  to  whenever  the  surgeon 
was  foiled  in  his  endeavours  to  introduce  a tube 
into  the  larynx,  in  suspended  respiration  from 
drowning,  hanging,  or  noxious  exhalation;  but  in 
asphyxia  from  these  causes,  bronchotomy,  in  the 
hands  of  a skilful  surgeon,  will  seldom,  if  ever,  be 
required. 

This  opinion  is  precisely  the  reverse  of  that  en- 
tertained by  Mr.  Samuel  Cooper,  who  is  an  advo- 
cate for  the  employment  of  bronchotomy  in  sus- 
pended respiration:  “From  the  manner  in  which 
the  epiglottis  covers  the  top  of  the  larynx,  it  is  ob- 
viously very  inconvenient  to  make  any  attempt  to 
introduce  the  muzzle  of  a pair  of  bellows  into  the 


OF  THE  HEAD  AND  NECK. 


40? 


rima  glottidis,  even  though  the  pipe  be  curved;  it 
is  much  better  to  have  recourse,  at  once,  to  a very 
safe  and  simple  operation,  which  consists  in  mak- 
ing an  opening  into  the  front  of  the  trachea,  suffi- 
cient to  admit  the  pipe  of  the  bellows.” 

While  writing  these  remarks,  the  author  has,  I 
suppose,  overlooked  the  substitute  proposed  by 
Desault,  and  most  happily  employed  both  in  France 
and  in  this  country.  That  celebrated  surgeon  was 
well  aware  of  the  difficulty  of  introducing  a pipe 
from  the  mouth  into  the  larynx.  Before  this  can 
be  done  the  epiglottis  must  be  commanded,  which 
is  not  an  easy  matter.  He  found,  however,  that  a 
tube  passed  along  the  right  nostril,  and  properly 
curved,  slipped  very  readily  into  the  opening  of 
the  glottis.  Here  there  was  no  obstacle  afforded 
by  the  epiglottis,  and  no  risk  of  folding  it  over 
the  top  of  the  larynx,  since  the  point  of  the  tube 
is  behind  the  line  of  that  valve.  This,  therefore, 
is  decidedly  the  mode  to  be  adopted  in  suspended 
respiration,  unless  where  the  subject  is  so  young, 
and  the  rima  so  small,  that  a proper  sized  canula 
cannot  be  introduced  into  the  trachea. 

As  the  facility  of  introducing  the  curved  tube 
by  the  nose  into  the  larynx,  will  entirely  depend 
on  the  possession  of  a correct  knowledge  of  the 
relation  of  the  larynx  to  the  nostril  and  adjacent 
parts,  I have  subjoined  a sketch,  which  will  illus- 
trate these  points  more  completely  than  can  be 
done  by  any  verbal  description. 


408 


ON  THE  SURGICAL  ANATOMY 


DESCRIPTION  OF  PLATE  X. 

While  preparing  this  sketch,  the  subject  was  laid  on  it» 
back,  and  the  left  half  of  the  lower  jaw  was  removed,  along 
with  that  side  of  the  pharynx.  By  keeping  the  tongue 
pulled  out  of  the  mouth,  the  bag  of  the  pharynx  is  fully  ex- 
panded, and  all  the  parts  are  rendered  distinct;  they  are 
placed  in  a situation  favourable  for  the  introduction  of  an 
instrument  from  the  nostril  into  the  larynx. 

This  view,  therefore,  will  be  useful  in  many  respects.  It 
illustrates  the  relation  of  the  epiglottis  and  the  rima  glotti- 
dis,  to  the  velum  pendulum  palati.  It  shews  how  easily 
a flexible  tube  may  be  passed  from  the  nostril  into  the 
rima,  and  it  at  the  same  time,  explains  the  cause  of  the 
difficulty  experienced  while  introducing  a pipe  from  the 
mouth  into  the  larynx. 

The  deepness  of  the  epiglottis,  and  the  facility  with 
which  that  valve  is  folded  over  the  rima,  render  the  intro- 
duction of  a tube  from  the  mouth  into  the  larynx,  by  no 
means  an  easy  process.  It  cannot  indeed  be  accomplished, 
till  the  finger  has  been  thrust  so  far  back  as  to  get  behind 
the  epiglottis.  If  this  be  managed,  and  if  that  valve  be 
laid  flat  along  the  dorsum  of  the  tongue,  a curved  flexible 
tube  may  be  conducted  along  the  finger  into  the  larynx. 
Where  the  muscular  action  is  completely  suspended,  the 
pipe  will  enter  readily  enough,  but  if  the  laryngeal  muscles 
be  still  irritable,  the  rima  will  be  closed  so  soon  as  it  is 
touched  by  the  tube;  the  point  of  the  instrument  will  slip 
back  into  the  pharynx,  and  the  stomach  will  be  inflated. 
All  this  has  frequently  happened,  and  that  time  which 
ought  to  have  been  employed  in  another  way,  has  been 
spent  in  futile  endeavours  to  get  the  tube  into  the  windpipe. 
This  delay  and  discomfiture  may  be  avoided  by  following 
the  practice  of  Desault. 


J?La.te 


ftrigrcLvcd,  5y  J.  Conc. 


OF  THE  HEAD  AND  NECK. 


409 


This  sketch  shews,  that  in  the  natural  condition  of  the 
throat,  the  epiglottis  A,  is  placed  nearer  to  the  mouth,  than 
the  line  of  the  posterior  face  of  the  velum  B-  By  passing, 
therefore,  the  curved  flexible  tube  C along  the  nose,  it  pre- 
sents behind  the  velum,  directly  over  the  riina  glottidis, 
into  which  it  may  be  directed  by  a pair  of  common  dressing- 
forceps  passed  along  the  mouth.  In  this  sketch,  a com- 
mon flexible  catheter  has  been  employed,  which  may  bb 
adapted  to  any  bellows,  by  merely  wrapping  folds  of  linen 
round  its  extremity,  till  it  be  made  of  a size  just  fitted  to 
slip  within  the  nozzle  of  the  bellows.  During  the  hurry, 
however,  and  the  confusion  usually  attendant  on  an  acci- 
dent requiring  inflation  of  the  lungs,  the  surgeon  sometimes 
overlooks  such  substitutes.  Hence  I have  actually  known 
a person  who  had  fallen  into  the  water,  allowed  to  lie 
without  any  attempt  having  been  made  to  inflate  the  lungs, 
till  a regular  apparatus  for  that  purpose  was  procured  from 
a distance. 

In  suspended  animation,  what  is  to  be  done  must  be  done 
quickly — there  is  no  leisure  for  deliberation — no  time  for 
experiments.  A surgeon  is  liable  every  hour  of  his  life  to 
be  called  on  to  give  his  assistance,  and  ought,  therefore,  to 
have  made  up  his  mind  how  to  act.  In  regard  to  inflating 
the  lungs,  there  cannot  remain  a doubt  about  the  propriety 
of  passing  the  tube  along  the  nostril;  the  structure  of  the 
throat  is  to  be  our  guide,  and  I will  venture  to  affirm,  that 
he  who  is  familiar  with  those  parts,  will,  without  difficulty, 
pass  a tube  from  the  nose  into  the  windpipe.  D the  uvula. 
E the  divided  body  of  the  hyoid  done.  F the  bag  of  the 
pharynx  terminating  in  G the  gullet,  which  just  at  its  com- 
mencement is  overhung  by  H the  thyroid  gland. 

By  permitting  the  tongue  to  fall  fairly  back  into  the 
mouth,  the  epiglottis  is  brought  considerably  behind  the 
line  of  the  velum.  In  that  situation,  an  instrument  intro- 
duced by  either  the  mouth  or  nose  strikes  on  the  valve, 
52 


410 


ON  THE  SURGICAL  ANATOMY 


and  folds  it  over  the  glottis.  This  is,  therefore,  the  situa- 
tion in  which  the  parts  ought  to  be  placed,  when  a tube  or 
the  probang  is  to  be  passed  along  the  oesophagus.  If  the 
tube  is  to  be  conveyed  from  the  nostril  into  the  gullet,  the 
base  of  the  skull  ought  to  be  kept  parallel  with  the  horizon^ 
but  where  we  are  to  pass  the  probang  along  the  mouth, 
ike  head  ought  to  be  turned  back. 


There  can  only  be  two  inducements  to  perform 
the  operation  of  bronchotomy,  one  to  admit  air 
Into  the  lungs,  the  other  to  remove  foreign  sub- 
stances from  the  windpipe.  Where  a solid  sub- 
stance has  entered  the  larynx,  it  can  seldom  be 
expelled — generally  an  operation  is  required  for 
its  removal.  If  permitted  to  remain,  even  where 
it  is  not  of  such  a size  as  to  obstruct  to  any  great 
degree  the  breathing,  when  it  first  slips  into  the 
larynx,  its  irritation  will  produce,  especially  in 
young  subjects,  inflammation  and  death. 

In  one  case  which  happened  in  this  town,  not 
very  long  ago,  a small  horse-bean  accidentally 
dropped  into  the  larynx  of  a young  child;  imme- 
diately her  breathing  became  exceedingly  difficult; 
an  incessant  cough  and  general  convulsions  nearly 
terminated  her  life.  She  continued  in  an  insen- 
sible state  for  half  an  hour,  during  which  she 
could  not  be  observed  to  breathe.  Then  the 
breathing  became  easy,  and  the  face  which  before 


OF  THE  HEAD  AND  NECK. 


411 


had  been  inflated  and  dark  coloured,  began  gra- 
dually to  resume  its  usual  complexion. 

Next  day  the  girl  had  another  attack  of  diffi- 
culty in  breathing,  which  after  a violent  paroxysm 
of  coughing,  abated,  but  left  her  in  a smart  fever. 
In  this  way  she  passed  a week,  during  which  she 
was  bled,  and  her  breast  was  blistered. 

It  may  be  proper  to  mention,  that  during  the 
whole  of  this  week  she  was  anxious  to  lie  on  her 
back,  and  also  that  at  the  commencement  of  the 
attack,  she  breathed  during  six  hours  with  a 
whistling  noise.  On  the  ninth  day  after  the  acci- 
dent, she  suddenly  died  during  a very  severe  fit 
of  coughing. 

Next  day  the  body  was  inspected,  the  larynx 
found  inflamed,  coated  in  part  with  lymphatic 
exudation,  and  containing,  just  below  the  rima,  a 
horse  bean. 

Other  cases  of  a similar  nature  have  come  to  my 
knowledge,  in  which  the  children  died  with  symp- 
toms of  cynanche  trachealis,  after  having  at  in- 
tervals threatening  of  instant  suffocation  from  the 
severity  of  the  cough.  When,  therefore,  a fo- 
reign substance  has  slipped  back,  and  the  child 
has  immediately  had  great  difficulty  in  breathing, 
violent  paroxysms  of  coughing,  followed,  in  a few 
days  by  symptoms  of  inflammation  of  the  larynx, 
we  cannot  be  enough  on  our  guard — we  cannot  too 
sedulously  watch  the  patient,  nor  can  we  too  soon 
endeavour  to  arrest  the  progress  of  the  inflamma- 


412 


ON  THE  SURGICAL.  ANATOMY 


tion;  I would  add,  that  this  cannot  he  accomplish- 
ed till  after  the  removal  of  the  foreign  substance, 
by  an  opening  made  into  the  windpipe.  Till, 
however,  the  opening  be  made,  we  seldom  can  be 
certain  that  there  really  is  any  extraneous  sub- 
stance lodged  in  the  trachea:  we  operate,  there- 
fore, on  a probability;  but  we  have  this  security, 
that  nothing  else,  if  there  be  a foreign  body  in  the 
windpipe,  will  save  the  life  of  the  patient.  There 
is,  therefore,  every  reason  to  induce  us  to  under- 
take the  operation,  and  none  to  deter  us. 

Where  a foreign  body  had  unquestionably  slip- 
ped into  the  larynx,  it  was  the  general  opinion, 
till  lately,  that  the  operation  of  bronchotomy 
would  only  be  useful  in  those  cases,  where  the 
substance  was  situated  above  the  point  where  the 
perforation  is  to  be  made.  It  was  universally  be- 
lieved, that  if  it  had  descended  along  the  canal 
of  the  trachea,  it  could  not  be  extracted  by  any 
opening  made  into  the  windpipe.  This  was  at 
least  a plausible  speculation;  it  therefore  main- 
tained its  ground,  till  disproved,  I believe,  by 
the  experiments  of  Favicr.  After  introducing 
a pea  fairly  into  the  trachea  of  a dog,  he  made  an 
opening  into  the  windpipe  below  the  thyroid 
gland,  and  found  that  by  the  force  of  the  air  ex- 
pelled from  the  lungs,  the  pea  was  thrown  out  by 
the  wound.  This  took  place  as  often  as  the 
foreign  substance  was  put  into  the  windpipe. 


OF  THE  HEAD  AND  NECK. 


413 


This  experiment,  uniform  in  its  result,  proves 
that  brorichotomy  will  be  equally  useful  where 
the  extraneous  substance  has  descended  into  the 
trachea,  as  where  it  has  been  impacted  in  the 
larynx.  In  the  human  subject,  I have  seen  a com- 
plete corroboration  of  this  fact. 

About  twelve  months  ago,  during  the  autumn, 
a young  woman  called  on  me  relative  to  a plumb 
stone  which  had  passed  into  the  trachea.  The 
account  which  she  gave  of  the  accident  was,  that 
she  had  been  eating  plumbs  two  days  before — 
that  in  a hurry  she  had  incautiously  attempted  to 
swallow,  at  the  same  time  that  she  was  inspiring. 
She  was  conscious  that  a stone  had  at  this  in- 
stant entered  the  windpipe,  where  it  excited  con- 
siderable irritation,  and  long  continued  and  se- 
vere coughing.  The  latter  had  greatly  abated 
in.  the  course  of  a few  hours,  and  at  the  time 
I saw  her,  was  only  momentarily  excited  by  forci- 
ble expiration.  I examined  her  carefully,  and 
ascertained  that  while  she  was  taking  air  into 
the  lungs,  the  foreign  substance  descended  with 
rapidity  along  the  trachea,  to  the  point  where  it 
bifurcates,  from  which,  during  extirpation,  it  was 
again  forced  up  into  the  larynx,  but  could  not, 
by  any  effort,  be  projected  through  the  rima. 
During  its  ascent  and  descent,  it  was  productive 
of  a tickling  sensation  along  the  course  of  the 
trachea. 


414 


ON  THE  SURGICAL  ANATOMY 


As  she  suffered  very  little  inconvenience  from 
its  presence,  she  would  not  submit  to  its  removal; 
she  was  fully  persuaded  that  it  would  come  away 
as  unexpectedly  as  it  had  entered.  Whether 
her  expectations  were  ever  realized,  I never 
heard;  but  the  fact  of  the  stone  changing  its 
position  from  the  larynx  to  the  bifurcation  of  the 
trachea,  is  quite  conclusive  as  to  the  fact  it  was 
meant  to  corroborate. 

In  performing  the  operation  of  bronchotomy, 
the  perforation  is  sometimes  made  into  the  la- 
rynx, and  sometimes  into  the  tranchea  below  the 
thyroid  gland.  Vicq.  D’Azyr  first  advised  the 
opening  to  be  made  between  the  thyroid  and  cri- 
coid cartilages,  and  in  this  county  larvngotomy 
was  afterwards  patronized  by  Mr.  Coleman. 
Notwithstanding  the  high  authority  of  the  cele- 
brated French  anatomist,  and  the  opinion  of  Mr. 
Coleman,  the  propriety  of  laryngotomy  in  prefer- 
ence to  tracheotomy,  may  be  doubted. 

In  the  former  we  enter  at  once  into  the  la- 
rynx, below  the  rirna  glottidis  indeed,  but  still 
too  much  in  the  vicinity  of  that  opening  not  to 
afford  just  ground  for  apprehension;  we  excite 
incessant  and  very  distressing  coughing. 

If  it  be  really  necessary  to  perform  bronchoto- 
my, let  it  be  done  at  least,  in  those  not  arrived 
at  the  age  of  puberty,  below  the  thyroid  gland; 
let  us  cut  into  the  trachea,  by  which  we  shall 
with  less  inconvenience  to  the  patient,  gain  all 


OF  THE  HEAD  AND  NECK.  415 

the  advantage  which  can  be  derived  from  a high- 
er incision.  Here  I need  hardly  remark,  that 
the  younger  the  subject,  the  more  easily  may 
tracheotomy  be  performed,  and  the  less  easily 
laryngotomy. 

It  may  be  proper  to  mention,  that  in  the  adult 
female,  the  conformation  of  the  neck  resembles, 
in  some  points,  the  young  subject.  In  her  the 
larynx  is  not  only  smaller  in  proportion  to  the 
body  than  in  the  male,  but  it  is  also  higher  placed 
in  the  neck.* 

When  we  have  resolved  on  performing  trache- 
otomy, caution  is  required  in  the  execution  of  the 
operation.  If  considerable  care  be  not  employ- 
ed, we  may  injure  some  of  the  arteries  about  the 
root,  of  the  neck. 

The  arteria  innominata  is  in  risk  in  some  sub- 
jects.  I have  seen  it  mounting  so  high  on  the  fore 
part  of  the  trachea,  as  to  reach  the  lower  border 
of  the  thyroid  gland.  Even  the  right  carotid 
artery  is  not  always  safe.  I am  in  possession  of 
a cast  taken  from  a boy  of  twelve  years  of  age, 
which  shews  the  right  carotid  artery  crossing 
the  trachea  in  an  oblique  direction.  In  this  sub- 
ject that  vessel  did  not  reach  the  lateral  part  of 
the  trachea,  till  it  had  ascended  two  inches  and  a 
quarter  above  the  top  of  the  sternum. 

Where  both  carotid  arteries  originate  from  the 
arteria  innominata,  there  is  considerable  danger  in 


Soemerring  de  Corporis  Humani  Fabrics,  vol.  vi.  p.  IS 


416  ON  THE  SURGICAL  ANATOMY 

performing  the  operation  of  tracheotomy,  for  in 
such  cases,  the  left  carotid  crosses  the  trachea 
pretty  high  in  the  neck.  Professor  Scarpa  has 
seen  a specimen  of  this  distribution  in  a male  sub- 
ject, and  I have  met  with  five. 

These  varieties  in  the  course  of  the  arteries, 
are  worthy  of  being  known  and  remembered;  they 
will  teach  the  operator  to  be  on  his  guard,  since 
he  can  never,  a priori , ascertain  the  arrangement 
of  the  vessels  with  any  degree  of  certainty.  It 
will  impress  on  his  mind  the  impropriety  of  using 
the  knife  further,  than  merely  to  divide  the  integ- 
uments and  fasciae.  If  he  then  clear  the  trachea 
with  the  finger,  he  will  never  injure  any  of  the 
large  arteries.  When  with  the  finger  he  has 
fairly  brought  the  trachea  into  view,  he  ought  to 
examine  carefully,  whether  any  of  the  large  arte- 
ries lie  in  front  of  it,  and  if  he  discover  one,  he  ought 
to  depress  it  toward  the  chest  before  he  penetrates 
into  the  windpipe. 

In  cutting  into  the  trachea,  the  preferable  plan 
is  to  cut  the  rings  from  below  upward,  avoiding  in- 
jury of  the  thyroid  gland.  Mr.  Cooper  seems  to 
eut  them  from  above  to  below,  at  least  if  we  mayr 
judge  from  his  directions,  not  to  have  the  incision 
carried  “at  all  below  the  first  bone  of  the  sternum, 
lest  the  subclavian  vein  should  unfortunately  be 
cut.”*  This  is  not,  however,  the  only  risk;  it 
has  been  seen  that  there  is  more  danger  of  injur- 


Cooper’s  First  Lines  of  the  Practice  of  Surgery,  p.  510. 


OF  THE  HEAD  AND  NECK. 


417 


ing  one  of  the  large  arteries,  since  these  mount 
higher  than  the  vein.  Whether,  however,  the  in- 
cision be  made  in  the  one  way  or  the  other,  it  ap- 
pears to  be  the  uniform  opinion,  that  cutting  the 
trachea  longitudinally,  is  preferable  to  cutting 
across  between  the  rings. 

In  a child  about  six  months,  the  arteria  innomi- 
nata,  when  on  a level  with  the  top  of  the  sternum, 
and  at  the  distance  of  an  eighth  part  of  an  inch 
from  its  division  into  the  carotid  and  subclavian 
vessels,  gave  off  from  its  left  side,  a branch  about 
the  size  of  a crow  quill.  This  ascended  along  the 
front  of  the  trachea,  for  about  a quarter  of  an  inch, 
and  there  divided  into  two  equal  sized  branches. 
From  the  left  branch  an  artery  of  some  size  was 
sent  into  the  thymus  gland,  which  in  this  child  was 
very  large.  Soon  after  the  origin  of  this  thymic 
branch,  the  artery  divided  into  six  twigs,  which 
finger-like  embraced  the  lower  margin  of  the  thy- 
roid gland.  The  other  division  of  the  artery  sent 
some  twigs  into  the  sterno-hyoid  and  thyroid  mus- 
cles, but  its  chief  twigs  passed  into  the  thyroid 
gland.  The  twigs  of  this  anomalous  artery,  which 
just  above  the  chest  were  few,  large,  and  close  to 
each  other,  subdivided  and  receded  as  they  as- 
cended, so  that  at  last  they  covered  not  only  the 
whole  fore  part  of  the  trachea,  but  even  overhung 
its  sides. 

From  the  sternum  up  to  the  thyroid  gland,  there 
was  hardly  a single  point  of  the  trachea  into  which 
53 


418  ON  THE  SURGICAL  ANATOMY 

an  incision  could  be  made,  without  dividing  some 
of  the  pretty  large  twigs  of  this  vessel.  This  is 
not  a solitary  case — I have  met  with  other  three 
children,  in  whom  there  was  a similar  arrange- 
ment of  the  vessels  going  to  the  thyroid  gland.  It 
is  well  to  know  these  facts;  not  that  they  afford 
any  objection  to  the  performance  of  tracheotomy, 
but  to  shew,  that  while  performing  that  operation, 
there  may,  from  the  division  of  the  twigs  of  this 
vessel,  be  considerable  bleeding. 

The  two  inferior  thyroid  arteries  arise  by  a 
common  trunk  from  the  right  subclavian  arter\ . in 
a preparation  in  the  possession  of  my  friend  Dr. 
Barclay.  In  this  subject,  the  vessel  creeps  up  the 
side  of  the  trachea,  lower  than  the  gland,  and 
when  it  has  reached  the  front  of  the  windpipe  it 
divides  into  two  branches.  The  right  branch  runs 
along  the  trachea,  and  the  left  ascends  till  within 
two  tracheal  rings  of  the  cricoid  cartilage.  The 
first  lies,  as  I have  been  informed,  nearly  in  the 
line  of  the  small  vein  which  generally  covers  the 
trachea,  and  which,  during  the  operation  of  tra- 
cheotomy, is  usually  divided. 

Haller,  when  describing  the  inferior  thyroid  ar- 
tery, mentions,  “semel  rarissimo  examplo,  a caro- 
tide  vide  natam;”*  but  as  he  does  not  specify  the 
course  of  the  vessel,  it  is  quite  uncertain  whether 
it  ran,  in  his  case,  in  such  a direction  as  to  come  in 


* Iconum  Anatomicarum  Fasciculus  \i.  p.  IS. 


OF  THE  HEAD  AND  NECK. 


419 


the  way  of  the  knife,  in  performing  the  operation 
of  tracheotomy. 

When  the  operation  of  bronchotomy  is  required 
in  the  adult,  laryngotoray  may,  by  some,  be  thought 
preferable  to  tracheotomy.  In  the  full  grown  per- 
son, the  space  between  the  lower  edge  of  the  thy- 
roid gland  and  the  sternum,  is  less  than  in  the  child, 
while  the  larynx  is  comparatively  much  larger. 
Laryngotomy,  therefore,  may,  in  the  adult,  have 
some  advantages;  but  tracheotomy  is  the  opera- 
tion adapted  to  the  mechanism  of  the  throat  in 
childhood.  In  tracheotomy,  the  anomalous  artery 
is  liable  to  come  in  the  way,  and  where  it  exists 
it  must  inevitably  be  divided.  In  laryngotomy, 
we  shall  more  rarely  meet  with  any  aberrant  ves- 
sel, although  even  here  they  sometimes  do  occur. 

In  one  subject  which  I dissected,  the  ramus  thy- 
roideus  arterise  thyroids  superioris  was  amazingly 
large,  being  considerably  bigger  than  a crow  quill, 
and  it  likewise  ran  in  an  uncommon  course.  This 
vessel  slipped  in  beneath  the  omo  and  sterno-hyoid 
muscles,  running  along  the  line  of  junction  ol  the 
hyo-thyroideus  and  sterno-thyroideus,  till  it  reach- 
ed the  front  of  the  neck.  Then  it  suddenly  turned 
downward  to  the  thyroid  gland,  wThich  it  touched 
at  the  central  part.  From  its  course  it  could  not 
have  escaped  in  laryngotomy;  it  would  have  pour- 
ed its  blood  into  the  windpipe. 

A large  vein  is  often  found  running  just  be- 
neath the  fascia,  and  between  the  contiguous 


420 


ON  THE  SURGICAL  ANATOMY 


edges  of  the  sterno-hyoidei  muscles.  This  vessel, 
in  performing  the  operation  of  laryngotomv,  would 
of  necessity  be  divided.  This  cannot  be  consi- 
dered as  forming  any  objection  to  that  operation; 
it  is  mentioned,  to  shew  that  there  may  be  bleed- 
ing, and  to  hint  the  propriety  of  securing  every 
vessel  which  may  be  injured  before  cutting  into 
the  larynx.  By  doing  so,  considerable  inconve- 
nience may  be  avoided. 

In  a patient  of  Mr.  Harrold’s,  who  had  cut  into 
the  larynx,  between  the  thyroid  and  cricoid  car- 
tilages, the  lips  of  the  wound  were  brought  closely 
together  by  sutures.  On  the  fifth  day  the  man 
died  suddenly.  A small  artery  had  poured  its 
blood  into  the  windpipe  and  formed  a coagulum 
there,  extending  even  into  the  branches  of  the 
trachea.* 

That  the  arteries  of  the  thyroid  gland,  and 
even  the  veins,  may  occasion  disagreeable  con- 
sequences, if  divided,  in  performing  the  operation 
of  tracheotomy,  is  incontrovertible:  “La  glande 
thyroide  envoie  inferieurement  a la  veine  soucla- 
viere  gauche,  des  veines  qui,  apres  s'*6tre  rami- 
fiees  a sa  face  anterieure,  se  reunissent  en  deux 
troncs  dont  celui  qui  est  a gauche  rampe  le  pius 
ordinairement  an  devant  de  la  trachee-artere, 
dans  l’intervalle  qui  separe  les  deux  muscles 
bronchiques,  a leur  partie  inferieure.  Ces  troncs 
n’en  torment  plus  qu’n,  a l’endroit  de  leur  inser- 

* W ilmer’s  Observations,  p.  92 — 93. 


OF  THE  HEAD  AND  NECK. 


421 


tion,  dans  le  plus  grande  nombre  de  sujets. 
Quelquefois  ils  restent  separes.  Quelquefois 
aussi  Pun  d’eux  aboutit  a la  souclaviere  gauche, 
et  Pautre  a la  souclaviere  droite.  Le  gauche 
pent  etre  interesse  dans  Pincision  du  tissu  grais- 
seux  qui  couvre  la  trachee-art  re.  Ce  canal  a 
lui-meme  des  vaisseaux  qui  lui  sont  propres,  et 
qui  peuvent  etre  ouverts  et  fournir  beaucoup 
de  sang.  C’est  ce  qui  est  arrive  dans  un  cas 
insure  par  Hevin  dans  son  memoire  sur  les  corps 
etrangers  arretes  dans  Poesophage  et  dans  la 
trachee-artere,  tome  premiere  des  Memoires  de 
PAcad.  de  Chirurg.  Un  soldat  Espagnol  age 
de  vingt-trois  ans,  etoit  pres  de  perir  de  suffo- 
cation dans  une  esquinancie.  On  jugea  qu’on 
ne  pouvoit  le  sauver  que  par  la  bronchotomie. 
La  tractive  art^re  ayant  ete  raise  a decouvert 
par  une  incision  longitudinale,  ce  canal  fut  ouvert 
entre  deux  anneaux  cartilagineux;  mais  le  malade 
n’en  eprouva  ancun  soulagement,  parce  que  le 
sang  y tomboit,  et  causoit  une  toux  convulsive 
qui  ne  permettoit  pas  de  maintenir  la  cannule 
en  place.  Le  cas  parut  si  pressant,  que  Vir- 
gili  ce  determina  a inciser  la  trachee-artere  en 
long  jusqu’au  sixieme  anneau,  apres  quoi  il  fit 
pencher  le  malade  en  devant.  Bientot  le  sang 
cessa  de  couler,  et  on  put  mettre  dans  la  plaie 
une  plaque  de  plomb  percee  de  plusieurs  trous, 
et  garnie  de  deux  atles  repliees  a peu  pres  com- 
me  celles  dont  Belloste  a fait  usage  dans  le  traite- 


422 


ON  SURGICAL  AN 4.TOMY. 


ment  de  la  plaie  du  trepan.  Des  le  lendemain, 
la  fievre  etoit  deminuee  et  la  deglutition  plus 
aisee.  Virgili  pensa  que  peutetre  le  malade 
pourroit  respirer  sans  le  secours  de  la  plaque,  et 
il  I’dta.  Ses  esperances  ne  furent  pas  trompees. 
II  ne  fut  plus  question  alors  que  de  rapprocher 
les  bords  de  la  plaie  et  de  travailler  a sa  con- 
solidation que  ne  tarda  que  quelques  jours  a se 
faire.”* 

The  thyroid  gland  itself  may  come  in  the  way 
of  the  knife,  while  performing  the  operation  of 
tracheotomy.  I,  in  one  subject,  found  the  slip  of 
the  thyroid  gland  which  crosses  the  front  of  the 
trachea,  so  broad,  that  it  descended  almost  to 
the  sternum.  This  conformation  must  be  remem- 
bered, because  by  injuring  the  substance  of  the 
gland,  a very  considerable  bleeding  will  be  occa- 
sioned, and  the  same  bad  effects  may  be  produced 
as  result  from  division  of  the  arteries  or  veins. 

* Medicine  Operatoire,  par  Sabatier,  tome  ii.  page  S60. 


OBSERVATIONS 


OV  THE 

STRUCTURE  OF  THE  NECK 

OP  THE 

EDENTULOUS  SUBJECT. 


In  an  edentulous  subject,  there  are  considera- 
ble peculiarities  in  the  relation  of  the  parts  about 
the  throat. 

In  some  points,  an  edentulous  person  bears  a 
resemblance  to  the  young  subject,  and  in  others 
it  is  similar  to  the  adult,  with  the  head  turned 
back;  but  it  has  also  a character  peculiar  to  its 
own  period  of  life. 

In  the  child,  from  the  non-evolution  of  the 
jaw  and  of  the  teeth,  the  large  vessels  at  the 
top  of  the  throat  are  fully  exposed;  the  parotid 
gland,  from  the  distance  between  the  angle  of 
the  jaw  and  the  anterior  edge  of  the  sterno-mas- 
toid  muscle  is  broad,  but  at  the  same  time  short, 
and  from  the  quantity  of  adipose  matter,  there 
is  a fulness  and  plumpness  which  is  lost  when 


424 


ON  THE  SURGICAL  ANATOMY 


the  fat,  instead  of  being  collected  exterior  to  the 
muscles,  is  more  regularly  distributed  among  their 
fibres  and  interstices. 

In  the  perfectly  formed  adult,  the  jaws  are 
broad,  their  circle  is  wide,  and  the  space  be- 
tween the  angle  and  the  mastoid  process  is  con- 
tracted. In  the  adult,  therefore,  the  parotid  is 
larger  but  of  less  breadth  than  in  the  child;  the 
primary  branches  of  the  carotid  and  the  styloid 
process,  are,  in  a great  measure,  covered  by  the 
jaw  bone,  and  there  is  a uniform  fulness  of  all  the 
parts. 

In  the  edentulous  subject,  there  is  not  only  a 
loss  of  the  teeth,  but  the  alveolar  processes  are 
likewise  absorbed.  By  the  falling  out  of  the 
teeth  and  the  loss  of  the  alveolar  processes,  the 
distance  between  the  palatine  plate  of  the  upper 
jaw  bone  and  the  chin  is  much  reduced;  again  the 
infantile  conformation  would  exist,  were  it  not 
from  the  length  of  the  lower  jaw. 

When  the  mouth  is  closed,  the  chin  is  raised 
and  projected  forward,  and  the  angle  of  the  jaw 
is  removed  from  the  mastoid  process;  the  space 
between  these  points  is  greatly  increased,  the 
breadth  of  the  parotid  gland  is  augmented,  a hol- 
lowness is  formed  behind  the  jaw,  the  whole  of 
the  styloid  process  is  uncovered,  and  the  large 
vessels  and  nerves  about  the  top  of  the  throat  are 
exposed. 


OF  THE  HEAD  AND  NECK.  425 

By  bringing  the  jaws  into  contact,  the  mylo- 
hyoideus,  and  the  anterior  belly  of  the  digastric, 
are,  even  when  the  base  of  the  skull  is  placed 
parallel  to  the  horizon,  put  on  the  stretch,  con- 
sequently the  submaxillary  gland  is  exposed;  it 
is  brought  almost  completely  below  the  margin 
of  the  jaw  bone.  In  this  respect,  therefore,  the 
edentulous  subject  resembles  the  adult  with  the 
head  turned  back;  in  other  points,  however, 
they  are  very  dissimilar.  In  the  edentulous  per- 
son, the  peculiarities  are  produced  by  alterations 
in  the  conformation  of  the  jaw,  chiefly  by  the 
loss  of  the  teeth  and  the  decay  of  the  alveolar 
processes. 

From  the  elevation  of  the  angle  of  the  eden- 
tulous jaw,  the  point  where  the  sterno-mastoid 
and  omo-hyoid  muscles  intersect  each  other,  is 
relatively  to  the  angle  of  the  jaw  as  low  seated  as 
in  the  young  subject.  In  the  perfect  adult  it  has 
been  shewn,  that  a line  drawn  from  the  point  of 
decussation  of  the  omo-hyoideus  and  sterno-mas- 
toid muscles,  to  the  angle  of  the  jaw,  follows  nearly 
the  course  of  all  that  part  of  the  common  carotid 
artery  above  that  spot,  and  likewise  of  a conside- 
rable portion  of  the  external  carotid.  In  the 
edentulous  body,  a line  drawn  in  the  same  direc- 
tion, is  very  far  from  following  the  course  of  the 
artery;  it  turns  forward  from  the  vessel,  with 
which  it  forms  an  acute  angle. 

54 


■ ■:  ■ 


■ ’ > 


APPENDIX. 


Note  A. — p .71. 

A case  similar  in  its  nature,  but  attended  with 
somewhat  different  symptoms,  came  under  my  own 
observation  in  the  year  1817.  I have  already 
published  this  case  in  the  tenth  number  of  the 
American  Medical  Recorder,  p.  194,  but  as  I con- 
sider it  one  of  great  interest,  and  one  which  proves 
most  forcibly  the  lesson  taught  in  the  text, — -the 
difficulty  of  ascertaining  before  death  the  exact 
nature  of  such  affections,  I shall  offer  no  apology 
for  transcribing  it. 

Mr.  J.  M‘C.  was,  at  the  period  of  his  death,  in 
the  forty  seventh  year  of  his  age.  He  was  a man 
of  superior  talents  and  of  remarkable  activity,  and, 
until  six  months  previous  to  his  dissolution,  had 
enjoyed  excellent  and  uninterrupted  good  health. 
In  the  autumn  of  the  year  1816,  he  was  attacked 
with  a severe,  and  as  he  and  his  physicians 
thought,  rheumatic  pain  in  the  lower  part  of  his 
neck.  It  was  continued,  nor  did  all  the  local  and 
general  remedies  used,  operate  towards  its  allevi- 


428 


APPENDIX. 


ation.  The  neck  was  again  and  again  examined} 
but  as  nothing  could  be  there  discovered  amiss, 
the  first  opinion  of  the  medical  gentlemen  was  re- 
tained, and  the  rheumatic  plan  of  treatment  per- 
severed in  until  the  patient’s  death. 

Although  suffering  severely  from  the  local  pain, 
Mr.  M*C.  did  not  confine  himself  constantly  to  his 
house;  but  was  actively  engaged  during  a great 
part  of  the  period  of  illness  in  arranging  his  affairs, 
which  from  commercial  convulsions,  had  become 
embarrassed. 

One  evening  in  the  month  of  April,  1817,  he  re- 
tired to  bed  in  his  usual  state  of  health,  and  was 
discovered  next  morning  in  a state  of  insensibility 
arising  from  apoplexy.  Under  this  attack  he  re- 
mained until  the  evening,  when  he  recovered  his 
sensibility;  but  after  conversing  with  his  friends 
rationally  for  about  an  hour  and  a half,  the  coma 
returned,  and  terminated  his  life  early  the  follow- 
ing morning.  I was  not  consulted  as  a medical 
man  during  Mr.  M’C’s  illness,  but  was  requested 
by  a friend,  one  of  the  physicians  who  had  attend- 
ed him,  to  conduct  the  dissection. 

The  apoplexy  being  the  most  prominent  feature 
in  the  case,  the  head  was  first  examined.  When 
the  convolutions  of  the  brain  were  exposed  by  the 
removal  of  the  scull-cap  and  dura  mater,  the  cere- 
bral veins  were  observed  very  much  distended 
with  blood.  But  although  the  dissection  of  the 
brain  was  conducted  with  the  utmost  care  and 


APPENDIX. 


429 


attention,  neither  sanguineous  nor  serous  effusion 
could  be  discovered  in  the  ventricles  or  substance 
of  that  organ.  The  general  and  very  great  tur- 
gescence  of  the  cerebral  vessels  was,  however, 
quite  sufficient  to  account  for  the  coma. 

On  opening  the  chest,  the  nature  of  the  original 
disease  was  at  once  exposed.  There  arose  from 
above  the  arch  of  the  aorta  a large  tumour,  which, 
projecting  sternally,  adhered  firmly  to  the  spinal 
aspect  of  the  sternum.  Upon  separating  this  con- 
nexion we  discovered  that  the  tumour  was  formed 
by  an  aneurism  of  the  arteria  innominata,  and  that 
the  sternum  where  pressed  on  had  become  ca- 
rious. The  transverse  vein  formed  by  the  union 
of  the  left  subclavian  and  jugular  veins,  presented 
a very  uncommon  appearance.  It  had  more  the 
character  of  a ligamentous  cord  than  of  a distend- 
ed vessel;  and  when  opened  it  was  found  filled 
with  coagulable  lymph,  which  completely  oblite- 
rated its  cavity.  Being  curious  to  ascertain  the 
cause  of  this,  I traced  it  carefully  downwards  to- 
wards the  right  auricle.  Upon  arriving  at  the 
sternal  aspect  of  the  aneurismal  tumour,  the  vein 
terminated,  that  portion  of  it  which  crossed  the  tu- 
mour, having  from  pressure  become  obliterated. 
The  tumour  measured  four  inches  in  its  transverse 
diameter,  and  three  in  its  longitudinal.  The 
depth  of  the  sac  from  its  spinal  to  its  sternal  sur- 
face was  two  inches  and  three  quarters.  From  its 
situation  it  completely  covered  and  concealed  the 


430 


APPENDIX. 


trachea  and  gullet.  The  whole  length  of  the 
arteria  innominata  was  involved  in  it,  and  those 
arteries  into  which  that  vessel  naturally  divides, 
arose  separately,  as  independent  branches  from 
the  spinal  aspect  of  the  aneurismal  sac.  Both  the 
superior  and  inferior  thyroidean  veins  were  en- 
larged and  distended  with  blood;  they  appeared 
to  be  the  channels  through  which  the  venous  blood 
from  the  left  superior  extremity  and  left  side  of 
the  head  and  neck  was  conveyed  to  the  pulmonic 
auricle. 

We  are  naturally  struck,  from  the  consideration 
of  this  case,  with  the  fact,  that  such  a derange- 
ment could  exist  in  the  arterial  system,  and  yet 
remain  undiscovered  until  after  the  patient’s 
death.  It  is  a very  rare  occurrence  even  for 
aneurisms  of  the  arch  of  the  aorta  to  remain  un- 
suspected. We  cannot,  it  is  true,  in  many  instan- 
ces, give  a positive  assurance  of  their  existence, 
but  the  palpitations  of  the  heart,  the  intermissions 
of  the  pulse,  and  those  painful  indescribable  pec- 
toral sensations  which  are  their  usual  attendants, 
leave  generally  in  the  mind  of  the  intelligent  prac- 
titioner little  doubt  of  their  presence. 

Another  fact  in  the  history  which  strikes  us  as 
curious,  is,  that  although  the  aneurismal  tumour 
was  situated  immediately  before  the  trachea  aud 
oesophagus,  although  it  had  from  its  enlargement 
obliterated  the  transverse  vein,  and  from  its  pres- 
sure rendered  the  upper  bone  of  the  sternum 


APPENDIX. 


431 


carious,  still  that  no  symptom  of  its  having  pressed 
either  on  the  aspera  arteria  or  gullet,  was  mani- 
fested during  the  life  of  the  patient.  Writers  on 
aortic  aneurisms  inform  us,  that  when  these  tu- 
mours are  situated  on  the  right  side  they  produce 
dysphagia,  when  on  the  left  dyspnoea.  Yet  in  this 
case  neither  of  these  symptoms  were  present.  Can 
it  be  supposed  that  the  enlargement  of  the  tumour 
was  directed  towards  the  sternum  by  the  force  of 
the  circulation?  That  the  blood  coagulating  upon 
the  anterior  inner  surface  of  the  sac,  and  remain- 
ing fluid  on  the  posterior,  that  the  current  of  the 
circulation  behind  directed  the  pressure  from  the 
trachea  and  gullet,  and  directed  it  towards  the 
sternum? 

I have  in  my  possession  the  morbid  parts  of 
both  Mr.  Burns’  patient,  and  likewise  those  which 
were  taken  from  the  above  case.  In  every  point 
of  structure  they  bear  a striking  resemblance  to 
each  other.  Indeed,  this  is  so  remarkable  that 
it  would  be  difficult  to  distinguish  the  one  pre- 
paration from  the  other.  In  the  record  of  their 
symptoms,  it  will,  however,  be  observed  that  they 
seemed  to  be  very  different.  A pulsation  situated 
above  the  clavicle,  was  in  Mr.  Burns’  patient  the 
symptom  which  chiefly  occupied  the  attention  of 
the  medical  attendants.  In  the  case  where  I 
conducted  the  dissection,  this  symptom  escaped 
altogether  the  observation  of  the  physicians. 
They  were  men  of  the  first  consideration,  yet, 


432  APPENDIX. 

they  declared  that  “no  ’pulsation  teas  to  he  dis- 
covered. y I must  confess  I am  sceptical  on 
this  subject,  the  thyroid  margin  of  the  tumour 
was  in  contact  with  the  sternal  margin  of  the 
thyroid  gland,  and  consequently,  the  pulsation 
must  have  been  observed,  had  the  examination 
been  conducted  with  attention.  The  probability 
is  that  the  symptom  of  rheumatism  was  the  only 
one  to  which  the  minds  of  the  physicians  in  at- 
tendance was  directed. 

It  is  worthy  of  remark,  that  the  rheumatic 
symptoms  which  was  so  prominent  in  Mr.  M‘C's 
case,  was  also  present  in  Mr.  Burns’  patient. 
Rheumatic  pains  in  such  a situation  so  local,  so 
obstinate,  and  so  severe,  are  always  to  be  viewed 
writh  suspicion.  That  rheumatism  does  frequent- 
ly occur  in  this  situation,  cannot  be  doubted;  but 
that  a pain  of  the  same  character  is  almost  a 
never  failing  attendant  on  aneurism  of  the  arch  of 
the  aorta  and  its  great  vessels,  should  never  be  for- 
gotten. The  rheumatic  pain  may  and  probably 
will  be  removed  by  medical  treatment,  the  aneur- 
ismal  never  can.  Let  this  fact  be  recollected  and 
we  may  be  assisted  in  forming  a just  prognosis  in 
eases  similar  to  those  we  have  recorded. 

Another  character  in  which  the  cases  resem- 
bled each  other,  was  the  disposition  to  apoplexy. 
In  Mr.  Burns’  patient,  there  were  “vertigo,  fai- 
lure of  the  sight,  a turgescence  of  the  veins  of 


APPENDIX. 


433 


the  head  and  neck.7’  In  ray  own  case  the  disease 
terminated  in  apoplexy. 

From  these  observations  it  will  appear,  that  the 
difference  in  the  symptoms  of  the  two  cases  was 
more  apparent  than  real,  and  demonstrates  the  ne- 
cessity of  examining  both  local  and  general  symp- 
toms before  we  form  an  opinion  as  to  the  nature 
of  obscure  diseases. 


Note  B. — p.  73. 

That  a ligature  may  be  passed  around  the  ar- 
teria  innominata,  so  as  to  stopt  the  circulation  of 
blood  through  it  without  materially  affecting  the 
functions  of  the  brain  or  the  actions  of  the  right 
superior  extremity,  is  a question  which  rests  no 
longer  on  speculation.  Dr.  Mott,  Professor  of 
Surgery  in  the  University  of  New  York,  has  ac- 
tually performed  the  operation  on  the  living  sub- 
ject. The  great  interest  of  this  case  will  be  a suf- 
ficient apology  for  the  very  long  extract  which  I 
m ke  from  it. 

“Since  the  publication  of  Allan  Burns’  inval- 
able  work  on  the  Surgical  Anatomy  of  the  Head 
and  Neck,  I have  been  in  the  habit  of  showing  in 
my  surgical  lectures  the  practicability  of  secur- 
ing in  a ligature  the  arteria  inuominata;  and  I 
55 


434 


APPENDIX. 


have  had  no  hesitation  in  remarking  that  it  was  my 
opinion,  that  this  artery  might  be  taken  up  for 
some  condition  of  aneurisms;  and  that  a surgeon, 
with  a steady  hand  and  a correct  knowledge  of 
the  parts,  would  be  justified  in  doing  it.  I felt 
myself  warranted  in  this,  from  the  singular  suc- 
cess which  this  celebrated  anatomist  informs  us 
attended  his  injections,  and  from  my  own  investi- 
gations of  this  subject.  If  the  right  arm,  right 
side  of  the  head  and  neck,  can  be  filled  with  in- 
jection, after  interrupting  its  passage  through  the 
innominata,  as  we  believe  they  can,  who  can 
doubt  the  possibility  of  the  blood  to  find  its  way 
there  also,  as  it  will  pass  through  thousands  of 
channels,  which  art  could  not  penetrate  even  by 
the  finest  injections?  The  well  known  anastomoses 
of  arteries,  and  the  great  resources  of  the  sys- 
tem in  cases  of  aneurism,  encouraged  me  to  be- 
lieve, that  this  operation  might  be  performed  with 
reasonable  prospects  of  success.  With  all  this 
sanction,  and  the  analogy  of  the  other  great  ope- 
rations for  aneurism,  I could  not  for  a moment 
hesitate  in  recommending  and  performing  the  ope- 
ration. 

“The  following  operation,  as  the  steps  of  it  will 
show,  was  performed  with  the  two-fcid  intention: 
1st,  of  tying  the  subclavian  artery  before  it  pas- 
ses through  the  scaleni  muscles,  if  it  should  be 
found  in  a fit  state;  and  2dly,  to  tie  the  arteria 
innominata  in  case  the  former  should  be  diseased 


APPENDIX. 


435 


or  too  much  encroached  upon  by  the  aneuris- 
mal  tumour. 

“Michael  Bateman,  aged  fifty-seven  years,  was 
born  in  Salem,  Massachusetts,  and  by  occupation  a 
seaman.  He  was  admitted  into  the  New  York  hos- 
pital on  the  first  of  March,  1818,  for  a catarrhal 
affection,  having  at  the  same  time  his  right  arm 
and  shoulder  much  swollen.  At  the  time  of  his 
admission  the  catarrh  being  thought  the  most 
considerable  disease  of  the  two,  he  was  received 
as  a medical  patient,  and  placed  under  the  care 
of  the  physician  then  in  attendance.  During  the 
three  first  weeks  of  his  residence  in  the  house, 
the  catarrh  had  greatly  yielded  to  the  remedies 
prescribed.  The  inflammation,  which  had  pro- 
duced an  enlargement  of  the  whole  superior  ex- 
tremity, extending  itself  to  the  muscles  of  the 
neck  on  the  right  side,  was  also  gradually  sub- 
siding. 

“A  tumefaction,  however,  situated  above  and 
posterior  to  the  clavicle,  at  first  involved  in  the 
general  swelling,  and  not  to  be  distinguished  from 
it,  began  to  show  itself.  This  resisted  the  reme- 
dies which  were  effectual  in  relieving  the  other, 
and  became  more  distinct  and  circumscribed  as  the 
latter  subsided;  at  length  assuming  the  form  of  an 
irregular  tumour. 

“The  history  which  he  gave  of  the  case  is  as  fol- 
lows: He  said,  about  a week  before  he  entered  the 
hospital,  while  at  work  on  ship-board,  his  feet  ac- 


436 


APPENDIX. 


ci dentally  slipped  from  under  him,  and  he  fell  upon 
his  right  arm,  shoulder,  and  the  back  part  of  his 
head;  that  he  felt  but  little  inconvenience  from  the 
fall,  and  after  a short  time  returned  to  his  duty. 
Two  days  subsequent  to  this,  however,  he  felt  pain 
in  the  shoulder,  and  the  succeeding  night  was  un- 
able to  lie  upon  it  in  bed.  The  whole  arm  and 
shoulder  then  began  to  swell,  and  became  so  pain- 
ful that  he  was  unable  any  longer  to  perform  his 
duty  as  a seaman.  The  ship  having  arrived  in 
New  York,  he  was  admitted  into  the  hospital. 

“For  some  time  after  the  general  swelling  had 
subsided,  leaving  the  tumour  distinct  and  circum- 
scribed, no  circumstance  occurred  which  gave  rise 
to  a suspicion  of  its  being  aneurismal.  The  en- 
largement was  thought  to  be  a common  indolent 
tumour,  and  was  repeatedly  blistered,  with  a view 
to  discuss  it.  The  tumour  gradually  diminished 
under  this  treatment;  though  a considerable  time 
elapsed  before  any  very  striking  change  took 
place. 

“At  length  a faint  and  obscure  pulsation  was 
perceived;  still  it  was  a matter  of  doubt  whether 
the  tumour  was  aneurismal,  or  whether  the  pul- 
satory motion  was  communicated  to  it  by  the  sub- 
clavian artery,  immediately  over  which  it  was  situ- 
ated. From  its  firm  unyielding  nature  upon  pres- 
sure, the  latter  was  considered  as  the  most  proba- 
ble, and  the  blisters  were  continued  as  before. 
During  the  whole  of  this  time  the  patient  had  worn 


APPENDIX. 


437 


his  arm  in  a sling,  the  motions  of  it  being  very 
limited,  and  always  attended  with  pain. 

“The  patient  remained  in  this  state  for  several 
days,  without  any  marked  change  either  in  his 
feelings,  or  in  the  appearance  of  the  tumour. 

“On  the  3d  of  May,  at  six  o’clock  in  the  after- 
noon, the  patient  complained  that  he  “felt  something- 
give  way  in  the  tumour,”  that  his  shoulder  was 
very  painful,  and  that  he  was  able  to  raise  it  only 
a few  inches  from  his  side.  The  tumour  at  this 
time  suddenly  increased  about  one  third,  and  a 
pulsation  was  distinctly  perceptible.  Its  most 
prominent  part  was  below  the  clavicle;  at  which 
place  the  pulsation  was  most  distinct.  The  por- 
tion above  the  clavicle  was  also  much  enlarged;  it 
still,  however,  had  its  usual  firmness,  except  in 
one  point  near  its  centre. 

“May  4th. — The  tumour  is  evidently  increased, 
that  portion  of  it  more  particularly  which  is  below 
the  clavicle;  it  is  not  as  firm  and  resisting  as  it  has 
been.  Pulsation  is  not  so  distinct  as  yesterday, 
but  appears  to  be  more  diffused. 

“He  was  this  day  transferred  to  the  surgical 
side  of  the  house,  and  became  my  patient.  The 
cough  having  become  comparatively  slight,  the  tu- 
mour appeared  to  be  the  most  urgent  disease,  and, 
in  my  opinion,  to  call  for  prompt  attention.  The 
arm  is  now  perfectly  useless,  and  any  motion  at 
the  shoulder  joint  gives  him  severe  p;  in.  The 
patient  is  naturally  of  a spare  habit,  and  from  the 


438 


APPENDIX. 


nature  of  his  disease,  and  the  confinement  to  which 
he  has  been  subjected,  has  become  much  reduced 
in  strength. 

“May  5th  and  6th. — The  tumour  is  still  pro- 
gressing, and  the  pain  in  the  shoulder  is  also  more 
severe.  During  the  three  last  days  his  medicines 
have  been  discontinued,  except  that  he  is  allowed 
to  rub  the  parts  about  the  clavicle  with  volatile 
liniment. 

“On  the  seventh  I directed  a consultation  of  my 
colleagues  to  be  called,  consisting  of  Drs.  Post, 
Kissam  and  Stevens.  I now  stated  to  them  that 
I wished  to  perform  an  operation  which  would 
enable  me  to  pass  a ligature  around  the  subclavian 
artery,  before  it  passes  through  the  scaleni  mus- 
cles, or  the  arteria  innominata,  if  the  size  of  the 
tumour  should  prevent  the  accomplishment  of  the 
former.  This  I was  permitted  to  do,  provided 
the  patient  should  assent,  after  a candid  and  fair 
representation  was  made  to  him  of  the  probable 
termination  of  his  disease;  and  that  the  operation, 
though  uncertain,  gave  him  some  chance,  and,  as 
we  thought,  the  only  one  of  his  life. 

“Dr.  Post,  at  my  request,  communicated  with 
him  privately  on  this  subject,  and  after  a full 
explanation  of  the  nature  of  the  case,  my  patient 
requested  to  have  any  operation  performed 
which  promised  him  a chance  for  his  life,  saying, 
that  in  his  present  case  he  was  truly  wretched. 


APPENDIX. 


439 


“May  8th,  9th,  and  10th. — The  tumour  is  ac- 
knowledged by  all  to  be  increasing,  and  it  is 
thought  proper  not  to  defer  the  operation  any 
longer.  I therefore  requested  that  preparation  be 
made  for  performing  it  to-morrow. 

“It  is  difficult  to  give  an  idea  of  the  size  of  a 
tumour  so  irregular  in  its  form,  and  so  peculiarly 
situated.  A thread  passed  over  it,  from  the 
lower  part  of  that  portion  of  it  which  is  below  the 
clavicle,  extending  upward  obliquely  across  the 
clavicle  toward  the  back  of  the  neck,  will  mea- 
sure five  and  a quarter  inches. — Another  crossing 
this  at  right  right  angles  one  inch  above  the  cla- 
vicle, will  measure  four  inches;  two  and  a half 
inches  of  the  thread  are  on  the  sternal  side  of  the 
former,  and  one  and  a half  on  the  acromial.  It 
rises  fully  an  inch  above  the  clavicle,  which, 
added  to  the  depression  below  the  clavicle  on 
the  opposite  shoulder,  will  make  the  size  of  the 
swelling  above  the  natural  surface  about  two 
inches. 

“May  11th. — One  hour  before  the  time  as- 
signed for  the  operation,  the  patient  appeared 
perfectly  composed,  and  apparently  pleased  with 
the  idea  that  the  operation  afforded  him  a pros- 
pect of  some  relief  He  was  directed  to  take  of 
tinct.  opii.  seventy  drops. 

“No  difference  can  be  perceived  in  the  pulsa- 
tion of  the  arteries  in  the  two  extremities;  his 


440 


APPENDIX. 


pulses  are  uniform  and  regular,  each  beating  sixty- 
nine  in  a minute. 

He  was  placed  upon  a table  of  the  ordinary 
height,  in  a recumbent  posture,  a "little  inclining 
to  the  left  side,  so  that  the  light  fell  obliquely 
upon  the  upper  part  of  the  thorax  and  neck. 
Seating  myself  on  a bench  of  a convenient  height, 
I commence  my  incision  upon  the  tumour,  just 
above  the  clavicle,  and  carried  it  close  to  this 
bone  and  the  upper  end  of  the  sternum;  and  ter- 
minated it  immediately  over  the  trachea;  making 
it  in  extent  about  three  inches.  Another  incision 
about  the  same  length,  extended  from  the  termina- 
tion of  the  first  along  the  inner  edge  of  the  sterno- 
cleido- mastoid  muscle.  The  integuments  were  then 
dissected  from  the  platysma  myoiues,  beginning  at 
the  lower  angle  of  the  incisions,  and  turned  over 
upon  the  tumour  and  side  of  the  neck. 

“Cutting  through  the  platysma  myoides,  I cau- 
tiously divided  the  sternal  part  of  the  mastoid- 
muscle,  in  the  direction  of  the  first  incision,  and 
as  much  of  the  clavicular  portion  as  the  size  of 
the  swelling  would  permit,  and  reflected  it  over 
upon  the  tumour.  The  internal  jugular  vein  was 
encroached  upon  by  the  swelling,  which  made 
this  part  of  the  operation  of  the  utmost  delicacy, 
from  the  morbid  adhesion  of  that  part  of  the  cla- 
vicular portion  of  the  muscle  to  it,  which  was 
detached.  I separated  this  portion  of  the  muscle 
to  as  great  an  extent,  however,  as  the  case  would 


APPENDIX. 


441 


possibly  allow,  to  make  room  for  the  subsequent 
steps  of  the  operation;  only  a part  of  the  vein 
was  exposed.  The  sterno-hyoid  muscle  was  next 
divided,  and  then  the  sterno-thyroid,  and  turned 
upon  the  opposite  side  of  the  wound  over  the  tra- 
chea. This  exposed  the  sheath  containing  the 
carotid  artery,  par  vagum,  and  internal  jugular 
vein.  A little  above  the  sternum,  1 exposed  the 
carotid  artery,  and  separated  the  par  vagum  from 
it;  then  drawing  the  nerve  and  vein  to  the  out- 
side, and  the  artery  towards  the  trachea,  I readily 
laid  bare  the  subclavian  about  half  an  inch  from 
its  origin.  In  doing  this,  the  handle  of  a scalpel 
was  principally  used,  nothing  more  being  re- 
quired but  to  separate  the  cellular  membrane,  as 
it  covers  the  artery.  I judged  it  would  be  very 
imprudent  to  introduce  a common  scalpel  into  so 
narrow  and  deep  a wound,  especially  as  it  would 
be  placed  between  two  such  important  vessels  or 
parts,  as  the  carotid  and  par  vagum,  and  where 
the  least  motion  of  the  patient  might  cause  a 
wound  of  one  or  the  other  of  them.  The  proper 
instrument,  in  my  opinion,  for  this  part  of  the 
operation,  is  a knife,  the  size  of  a small  scalpel, 
with  a rounded  point,  and  cutting  only  at  the  ex- 
tremity; this  was  used,  and  found  to  be  very  con- 
venient for  this  stage  of  the  operation.  It  can  be 
introduced  into  a deep  and  narrow  wound,  among 
important  parts,  without  the  hazard  of  dividing 
any  but  such  as  are  intended  to  be  cut. 

56 


442 


APPENDIX. 


“On  arriving  at  the  subclavian  artery,  it  ap- 
peared to  be  considerably  larger  than  common, 
and  of  an  unhealthy  colour;  and  when  I exposed 
it  to  the  extent  of  about  a half  an  inch  from  its 
origin,  which  was  all  that  the  tumour  would  per- 
mit, to  ascertain  this  circumstance  more  satisfac- 
torily, my  friends  concurred  with  me  in  opinion, 
that  it  would  be  highly  injudicious  to  pass  a liga- 
ture around  it.  The  close  contiguity  of  the  tu- 
mour would  of  itself  have  been  a sufficient  objec- 
tion to  the  application  of  the  ligature  in  this  situ- 
ation, independent  of  the  apparently  altered  state 
of  the  artery. 

“While  separating  the  cellular  substance  from 
the  lower  surface  of  the  artery,  with  the  smooth 
handle  of  an  ivory  scalpel,  a branch  of  an  artery 
was  lacerated,  which  yielded  for  a few  minutes  a 
very  smart  haemorrhage,  so  as  to  fill  the  wound 
perhaps  six  or  eight  times.  It  was  about  half  an 
inch  distant  from  the  innominata,  and  from  the 
stream  emitted,  was  about  the  size  of  a crow- 
quill.  It  stopped  with  a little  pressure.  I can 
scarcely  believe  this  to  have  been  the  internal 
mammary,  from  the  haemorrhage  ceasing  so 
quickly;  though,  from  its  situation,  it  would  ap- 
pear so;  and  if  from  some  irregularity  it  were  not 
the  superior  intercostal,  it  must  have  proceeded 
from  an  anomalous  branch. 

“With  this  appearance  of  disease  in  the  subcla- 
vian artery,  it  only  remained  for  me  either  to 


APPENDIX. 


443 


pass  the  ligature  around  the  arteria  innominata, 
or  abandon  my  patient.  Although  I very  well 
knew,  that  this  artery  had  never  been  taken  up 
for  any  condition  of  aneurisms,  or  ever  performed 
as  a surgical  operation,  yet  with  the  approbation 
of  my  friends,  and  reposing  great  confidence  in 
the  resources  of  the  system,  when  aided  by  the 
noblest  efforts  of  scientific  surgery,  I resolved 
upon  the  operation. 

“The  bifurcation  of  the  innominata  being  now 
in  view,  it  only  remained  to  prosecute  the  dis- 
section a little  lower  behind  the  sternum.  This 
was  done  mostly  with  the  round  edged  knife, 
taking  care  to  keep  directly  over  and  along  the 
upper  surface  of  the  artery.  After  fairly  denud- 
ing the  artery  upon  its  upper  surface,  I very  cau- 
tiously, with  the  handle  of  a scalpel,  separated 
the  cellular  substance  from  the  sides  of  it,  so  as  to 
avoid  wounding  the  pleura.  A round  silken  lig- 
ature was  now  readily  passed  around  it,  and  the 
artery  was  tied  about  half  an  inch  below  the  bi- 
furcation. The  recurrent  and  phrenic  nerves 
were  not  disturbed  in  this  part  of  the  operation. 

“In  no  instance  did  I ever  view  the  counte- 
nance of  man  with  more  fluctuations  of  hope  and 
fear,  than  in  drawing  the  ligature  upon  this  arte- 
ry. To  intercept  suddenly  one  fourth  of  the 
quantity  of  blood,  so  near  to  the  heart,  without 
producing  some  unpleasant  effect,  no  surgeon,  a 
priori,  would  have  believed  possible.  I there- 


444 


APPENDIX. 


fore  drew  the  ligature  gradually,  and  with  iny 
eyes  fixed  upon  his  face,  I was  determined  to  re- 
move  it  instantly  if  any  alarming  symptoms  had 
appeared.  But,  instead  of  this,  when  he  show- 
ed no  change  of  feature  or  agitation  of  body,  my 
gratification  was  of  the  highest  kind. 

“Dr.  Post  now  asked  him  if  he  felt  any  unplea- 
sant sensation  about  his  head,  breast  or  arm,  or 
felt  any  way  different  from  common,  to  which  he 
replied,  that  he  did  not. 

“Immediately  after  the  ligature  was  drawn 
tight,  the  tumour  was  reduced  in  size  about  one 
third,  and  the  course  of  the  clavicle  could  be 
distinctly  felt. 

“The  parts  were  now  brought  into  coaptation, 
and  the  integuments  drawn  together  by  three 
interrupted  sutures  and  straps  of  adhesive  plais- 
ter;  a little  lint  and  additional  straps  completed 
the  dressing.  Three  small  arteries  were  tied  in 
the  course  of  the  operation:  the  first  was  under 
the  sternum*  and  divided  with  the  sternal  part  of 
the  mastoid  muscle,  and  from  its  course  may 
have  been  a branch  of  the  internal  mammary  re- 
flected upwards;  the  second,  in  raising  the  inner 
edge  of  the  mastoid  muscle,  about  the  upper  an- 
gle of  the  longitudinal  incision,  and  must  have 
been  the  most  descending  branch  of  the  superior 
thyroid;  and  the  third,  was  a branch  of  the  in- 
ferior thyroid,  and  cut  while  raising  the  sterno 
thyroid  muscle.  The  patient  lost  perhaps  from 


APPENDIX. 


445 


two  to  four  ounces  of  blood,  most  of  which  came 
from  the  ruptured  branch  of  the  subclavian.  The 
operation  occupied  about  one  hour. 

“Ten  minutes  after  the  operation  the  pulse  is 
regular,  and  not  the  least  variation  can  be  per- 
ceived; it  beats  sixty-nine  strokes  in  a minute; 
the  patient  says  he  is  perfectly  comfortable,  and 
has  no  new  or  unnatural  sensation,  except  a little 
stiffness  of  the  muscles  of  the  neck,  which  he 
thinks  is  owing  to  the  position  in  which  his  head 
was  placed  during  the  operation;  the  tempera- 
ture of  the  right  arm  is  a little  cooler  than  the 
left;  his  breathing  has  not  been  the  least  affect- 
ed by  the  operation,  but  is  perfectly  free  and 
natural. 

“Two  o’clock,  p.  m. — Patient  expresses  a desire 
to  eat,  and  is  directed  a little  thin  soup  and 
bread;  the  temperature  of  both  arms  is  very 
nearly  the  same;  breathing  perfectly  natural; 
pulse  as  before. 

“Three  o’clock,  p.  m. — There  is  still  a trifling 
difference  in  the  temperature  of  the  two  arms;  or- 
dered the  right  to  be  wrapped  in  cotton  wadding; 
not  the  least  unpleasant  symptom  has  as  yet  made 
its  appearance. 

“Six  o’clock,  p.  m. — Complains  of  a little  pain 
in  his  head,  not  more  on  one  side,  however,  than  the 
other;  describes  it  as  a common  head-ache:  the 
pain  of  the  shoulder  and  arm  much  less  than  be- 
fore the  operation:  no  difference  can  now  be  per- 


446 


APPENDIX. 


ceived  in  the  temperature  of  the  two  arms;  pulse 
a little  accelerated,  and  perhaps  a little  full. 

“Nine,  p,  m. — Patient  complains  of  head-ache; 
skin  is  rather  hotter  than  natural,  pulse  strong 
and  full,  and  beats  seventy- five  in  a minute;  the 
carotid  on  the  left  side  of  the  neck  is  observed  to 
be  much  dilated  and  in  strong  action;  tongue  moist 
and  clean. 

“Half  past  nine,  p.  m. — Symptoms  continuing  the 
same,  directed  him  to  be  bled  from  the  left  arm  to 
sixteen  ounces.  After  bleeding  the  pulse  fell  se- 
ven beats,  and  was  less  full.  Complains  of  some 
thirst;  let  him  drink  common  tea. 

“Twelve,  p.  m. — Patient  has  slept  a little;  is 
free  from  pain;  pulse  full  and  less  frequent,  beats 
sixty;  skin  moist  and  of  a natural  temperature.” 
From  the  daily  reports  given  of  the  case,  it  ap- 
pears that  no  disagreeable  symptom  occurred  until 
the  twenty-third  day  after  the  operation.  Indeed, 
the  patient  felt  so  well  on  the  twentieth  day,  that 
he  was  enabled  to  walk  down  two  pair  of  stairs 
and  several  times  across  the  yard.  The  report  of 
the  twenty-third  day  is  as  follows: 

“ Twenty-third  day. — A few  minutes  before  the 
hour  of  visiting  to-day,  a message  was  brought 
that  the  patient  was  bleeding  from  the  wound. 
The  dressings  were  immediately  torn  off,  and  dry 
lint  crowded  into  the  wound,  and  slight  pressure 
applied  for  a few  minutes,  when  the  haemorrhage 
ceased.  The  patient  lost  at  this  time, perhaps,  about 


APPENDIX. 


447 


twenty-four  ounces  of  blood,  and  was  very  much 
prostrated.  Pulsation  ceased  in  the  radial  artery 
of  the  left  arm,  and  the  countenance,  gasping,  and 
convulsive  throes  of  the  patient,  threatened  im- 
mediate dissolution;  all  present  apprehended  the 
instant  death  of  the  patient.  The  first  impres- 
sion was,  that  the  trunk  of  the  arteria  innominata 
had  given  way.  The  conjecture  afterwards  was, 
that  the  subclavian  artery,  from  the  diseased  state 
of  it,  had  not  united  by  adhesion,  and  that  the 
fluid  blood  from  the  tumour  had  regurgitated 
through  its  ulcerated  coats.  This  appeared  to  be 
the  most  probable,  both  from  the  suddenness  with 
which  the  blood  ceased  flowing,  and  the  cause  the 
patient  assigned  for  the  haemorrhage.  He  says, 
that  he  felt  weary  of  lying  on  his  left  side  and 
back;  that  he  had  just  turned  on  the  right,  which 
he  had  not  done  before  since  the  operation,  agree- 
ably to  my  request.  At  the  instant  of  turning 
over,  something  arrested  his  attention,  which 
caused  him  to  turn  his  head  to  the  opposite  side 
suddenly,  and  he  felt  the  gush  of  blood  from  the 
wound. 

“He  was  directed  some  wine  and  water  fre- 
quently, which  soon  revived  the  circulation.  The 
wound  was  dressed  with  dry  lint  and  a compress. 
Pulse  as  frequent  as  natural,  but  very  small  and 
soft:  he  appears  very  languid,  and  complains  of  a 
numbness  and  painful  sensation  in  his  hands; 
says  also  that  his  back  aches.  During  the  last 


448 


APPENDIX. 


twenty-four  hours  he  has  taken  a pint  and  a half 
of  Madeira  wine:  he  also  took  occasionally  some 
egg  and  wine,  which  was  immediately  rejected 
from  the  stomach. 

“Nine,  p.  m. — Patient  has  lost  his  appetite,  and 
appears  considerably  depressed;  circulation  very 
languid  in  the  right  arm;  temperature  of  it  is  a 
little  less  than  the  left:  directed  a hot  brick  to 
be  wrapped  in  flannel,  and  placed  close  to  the 
arm.  For  a profuse  perspiration  which  he  has 
been  in  for  the  last  three  hours,  he  was  ordered 
to  be  bathed  with  cold  rum. 

“Twenty -fourth  day . six,  a.m. — Slept  the  great- 
er part  of  the  night,  and  feels  comfortable;  is  still 
languid,  and  has  no  disposition  to  eat  any  thing: 
says  he  feels  sick,  and  once  last  evening  vomited 
after  drinking  some  wine  and  water. 

“Wound  looks  exceedingly  pale,  and  the  dis- 
charge is  thin  and  foetid,  for  which  the  carbon  and 
yest  dressings  were  applied.  He  has  vomited  se- 
veral times  to-day,  and  has  some  considerable 
difficulty  in  swallowing  and  complains  of  a sore- 
ness in  the  wound  upon  pressure. 

“Nine,  p.  m. — Dressings  removed;  wound  very 
pale;  right  arm  of  the  natural  temperature;  feels 
occasionally  a little  numbness  in  the  hand;  has 
taken  very  little  nourishment  during  the  day; 
pulse  natural  as  to  frequency,  but  small  and 
feeble;  a few  minutes  after  dressing  the  wound, 
information  was  brought  that  hsemorrnage  had 


APPENDIX. 


449 


ensued  and.  before  it  could  be  commanded,  he  pro- 
bably lost  four  ounces  of  blood.  For  his  restless- 
ness and  pain  in  the  bones  he  was  ordered  two 
grains  of  opium. 

“Twenty -fifth  day. — Has  rested  well  during  the 
night,  and  is  perhaps  a little  better  this  morning. 
The  repeated  haemorrhages  have  debilitated  him 
exceedingly,  and  from  the  irritable  state  of  the 
stomach  he  can  take  only  a very  little  nourishment. 
In  the  morning  he  was  directed  the  effervescing 
draught,  to  be  repeated  every  two  hours;  this  al- 
layed the  irritability  of  his  stomach,  and  enabled 
him  to  take  a little  breakfast. 

“His  countenance  has  altered  since  the  first 
bleeding  surprisingly,  his  eyes  are  nowr  heavy,  and 
for  the  most  part  fixed;  his  cheeks  are  sunken, 
and  an  universal  palor  has  spread  itself  over  his 
countenance;  and  from  every  appearance,  a short 
time  will  terminate  his  existence.  He  has  not  vo- 
mitted  since  early  in  the  morning;  is  advised  to 
take  a little  soup,  and  to  drink  freely  of  wine  and 
water;  dressings  were  renewed  at  three  o’clock, 
p.  m.  shortly  after  which  the  patient  again  bled, 
but  not  to  exceed,  however,  an  ounce,.  He  was 
dressed  with  dry  lint  as  usual. 

“Eleven,  p.  m. — Patient  has  not  as  yet  had  any 
sound  sleep,  is  restless  and  apparently  distressed, 
although  he  says  he  feels  no  pain;  breathing  is 
attended  with  some  difficulty;  his  hands  and  legs 
are  continually  in  motion;  pulse  small  and  feeble. 

57 


450 


APPENDIX. 


“ Twenty  sixth  day , six,  a.  m. — Patient  has  not 
rested  well;  is  occasionally  falling  into  little 
slumbers,  but  is  awaked  by  the  least  motion: 
Pulse  small  and  feeble;  respiration  somewhat  la- 
boured; appears  to  be  sinking;  seems  disinclined 
to  take  any  thing;  legs  and  arms  constantly  in 
motion. 

“Eleven,  a.  m. — More  feeble  than  before;  has 
been  forced  to  take  a little  chocolate;  is  evidently 
sinking;  wound  was  dressed,  but  there  was  no 
secretion  of  pus  in  it;  countenance  of  the  patient 
foretells  his  approaching  dissolution. 

“Six,  p.  m. — Is  extremely  low;  respiration  very 
laborious;  is  not  able  to  articulate:  for  the  last 
three  hours  there  has  not  been  such  continued 
throwing  of  the  legs  and  arms  about  the  bed: 
be  lays  in  a state  of  insensibility;  temperature 
of  the  two  arms  the  same  to  the  last . My 

pupil,  Mr.  Abraham  I.  Duryee,  the  house  sur- 
geon, (to  whom  I am  indebted  for  the  correct  re- 
ports, and  the  most  unwearied  attention  to  this 
case,  and  whose  ingenious  application  of  means 
for  the  recovery  of  many  of  my  patients,  will  long 
be  held  by  them  in  grateful  re  me  mo  ranee,)  having 
for  a few  minutes  left  the  patient,  he  was  sent  for 
immediately,  as  there  was  another  bleeding  from 
the  wound,  by  which  he  lost  probably  eight  ounces 
of  blood:  during  the  whole  time  he  did  not  mani- 
fest the  least  appearance  of  consciousness,  nor 
was  the  least  motion  perceptible,  except  that 


APPENDIX. 


451 


necessary  for  respiration  and  circulation:  the  hse- 
morrhage  was  stopped  with  lint  after  removing  the 
former  dressings;  respiration  is  now  performed  with 
the  utmost  difficulty,  and  the  patient  appears  as  if 
every  respiration  would  be  the  last:  he  expired  at 
half  past  six  in  the  afternoon:  the  temperature  of 
the  right  arm  after  death,  appeared  by  the  touch 
to  be  the  same  as  the  left.  It  was  as  natural  and 
uniform  as  other  parts  of  the  body. 

Examination  of  the  Body. 

“About  eighteen  hours  after  death,  I opened 
his  body;  there  was  considerable  emaciation,  and 
the  surface  of  the  wound  was  of  a dark  brown 
colour,  and  foetid;  the  wound  was  perhaps  about 
one  third  of  its  original  size;  it  had  been  enlarged 
by  the  pressure  of  lint  into  it,  and  other  means 
to  arrest  from  time  to  time  the  haemorrhage:  the 
ulcer  between  his  shoulders  was  ill  conditioned. 

“For  the  purpose  of  examining  the  condition  of 
the  aorta,  where  the  arteria  innominata  is  given 
olf,  as  also  the  origin  of  the  latter  vessel,  as  well 
as  the  state  of  the  pleura  at  the  part  about  which 
the  ligature  had  been  applied  around  the  artery, 
the  chest  was  opened  in  the  following  manner: 
after  removing  the  integuments  and  muscles  from 
the  fore  part  of  the  chest,  the  sternum  was  care- 
fully sawed  through  about  an  inch  from  its  upper 
extremity,  and  raised  by  sawing  through  the  ribs 
below  the  junction  of  the  cartilages;  this  removed 


452 


APPENDIX. 


so  much  of  the  front  part  of  the  chest  as  to  facili- 
tate and  expose  fully  to  view  the  subsequent  steps 
of  the  dissection;  by  thus  leaving  the  clavicles  at- 
tached, every  part  connected  with  the  ulcer  and 
great  vessels  could  be  seen  and  examined  in  situ. 

“The  arch  of  the  aorta  and  origin  of  the  inno- 
minata  being  fairly  exposed,  not  a vestige  of  in- 
flammation or  its  consequences  could  be  disco- 
vered, either  upon  them,  the  lungs,  or  the  pleura, 
at  any  part.  An  incision  was  next  made,  longi- 
tudinally into  the  aorta  opposite  the  origin  of  the 
innominata,  and  upon  introducing  a probe  cau- 
tiously up  the  latter  vessel,  it  was  seen  to  pass 
into  the  cavity  of  the  ulcer;  the  innominata  was 
then  laid  open  with  a pair  of  scissors  into  the 
ulcer;  the  internal  coat  of  this  vessel  was  smooth 
and  natural  about  its  origin,  but  for  half  an  inch 
below  where  the  ligature  bad  cut  through  the 
artery,  it  showed  appearances  of  inflammation, 
and  there  was  a coagulum  adhering  with  conside- 
rable firmness  to  one  of  its  sides;  showing  that 
nature  had  made  an  effort  to  plug  up  the  extre- 
mity of  so  large  a vessel,  after  the  adhesion, 
which  no  doubt  had  been  effected  by  the  ligature, 
was  swept  away  by  the  destructive  process  of 
ulceration.  The  upper  extremity  of  this  vessel 
was  considerably  diminished  in  its  diameter  by 
the  thickened  state  of  its  coats,  occasioned  by  the 
surrounding  inflammation.  The  innominata  about 
half  an  inch  from  the  aorta,  and  a little  to  the  left 


APPENDIX. 


453 


side,  gave  off  an  anomalous  artery  large  enough 
to  admit  a small  size  crow  quill. 

“The  ulcer  at  the  bottom  was  more  than  twice 
the  size  of  the  wound  in  the  neck;  it  extended  la- 
terally towards  the  trachea;  and  under  the  clavi- 
cle, towards  the  tumour.  The  tripod  of  great 
vessels,  consisting  of  the  innominata,  subclavian, 
and  carotid  arteries,  to  the  extent  of  nearly  an 
inch,  was  dissolved  and  carried  away  by  the  ul- 
ceration. The  extremities  of  the  two  latter  ves- 
sels were  found  also  to  open  into  the  cavity  of  the 
ulcer.  The  upper  surface  of  the  pleura  was 
very  much  thickened  by  the  deposit  of  newly 
organized  matter,  for  the  safety  and  protection  of 
the  cavity  of  the  thorax.  Indeed,  instead  of 
having  increased  the  danger  of  penetrating  this 
membrane,  the  adhesive  inflammation  which  pre- 
ceded the  ulcerative,  seemed,  by  the  consolidation 
of  cellular  membrane,  and  the  addition  of  new 
substance,  to  have  more  securely  and  effectually 
shielded  it  from  danger. 

“The  internal  surface  of  the  carotid  artery  was 
lined  with  a coagulum  of  blood,  more  than  twice 
the  thickness  of  its  coats,  and  extending  above 
the  division  into  internal  and  external,  so  as  al- 
most to  give  them  a solid  appearance,  insomuch 
that  a probe  could  barely  be  introduced.  The 
subclavian  artery,  internally  and  externally  to 
the  disease,  was  pervious.  The  brachial  and 
other  arteries  of  the  right  arm  were  of  their  com- 


454 


APPENDIX. 


mon  diameter,  and  in  every  respect  natural. 
The  external  thoracic  or  mammary  arteries,  as 
they  went  off  from  the  subclavian,  were  larger 
than  natural:  the  right  internal  mammary  was 
pervious,  and  of  the  usual  appearance.  Upon 
opening  into  the  tumour,  which  now  gave  (from  its 
small  size,)  no  deformity  to  the  shoulder,  the  cla- 
vicle was  involved  in  it,  and  found  carious,  and 
entirely  disunited  about  the  middle.  A number 
of  lymphatic  glands  under  the  clavicles,  and  par- 
ticularly the  left,  were  considerably  enlarged,  and 
when  cut  into,  very  soft,  and  evidently  in  a state 
of  scrophulous  suppuration.  No  other  morbid  ap- 
pearances were  observed.” 

Although  this  case  terminated  unfortunately  still 
its  result,  in  so  far  as  it  concerns  the  operation  of 
tying  the  arteria  innominata,  must  be  considered 
as  conclusive  evidence  of  its  practicability.  The 
operation  was  in  fact  so  far  as  it  was  immediate- 
ly concerned,  successful;  no  alarming  symptoms 
followed  the  tightening  of  the  ligature,  and  the 
obstruction  of  the  circulation  through  the  channel 
of  the  vessel;  the  patient  continued  to  improve  in 
his  health  until  the  twenty-third  day,  when  a hae- 
morrhage took  place  from  an  ulceration  of  tiie 
coats  of  the  artery,  an  ulceration  which  fre- 
quently has  occurred  in  instances  where  even  the 
smaller  arteries  have  been  tied.  If  I might  be  per- 
mitted to  offer  a criticism  gu  the  performance  of 
an  operation,  so  novel  in  its  character  and  so  bold 


APPENDIX. 


455 


in  its  design,  I should  feel  disposed  to  object  to 
the  previous  exposure  of  the  subclavian  artery. 
Indeed  I am  inclined  to  think,  that  it  was  from 
the  destruction  of  the  vasa  vasorura  of  so  large  a 
portion  of  the  artery,  that  the  fatal  haemorrhage 
is  to  be  attributed,  and  I can  hardly  doubt  from 
the  facts  of  the  case  that  had  the  arteria  innomi- 
nata  been  at  once  exposed  and  tied,  without  any 
reference  to  the  subclavian  artery,  that  the  event 
would  have  been  different.  This  opinion  I deliv- 
er, not  with  the  view  of  detracting  from  the  credit 
due  to  the  intrepid  operator,  but,  only  from  a de- 
sire to  support  and  corroborate  the  sentiments  of 
Mr.  Burns. 

I cannot  dismiss  this  case  without  adverting  to 
the  very  unfair  and  unhandsome  criticisms  which 
have  been  made  on  it,  in  some  of  the  periodical 
journals  of  this  country.  It  is,  however,  the  fate 
of  all  who  become  the  improvers  of  science,  to  be 
assailed  by  the  malice  and  envy  of  their  less 
distinguished  cotemporaries.  Dr.  Mott  has  the 
satisfaction  of  knowing  that  their  attempts  to  in- 
jure his  reputation  have  proved  abortive,  for  the 
verdict  of  his  merit  is  now  attested  by  the  most 
eminent  and  honorable  members  of  his  profession. 


456 


APPENDIX, 


Note  C. — p.  195. 

Mr.  Burns  is  not  singular  in  giving  an  exagger- 
ated account  of  the  dangers  and  difficulties  attend- 
ant on  the  operation  of  tying  the  carotid  artery. 
His  never  having  had  an  opportunity  of  passing 
a ligature  around  that  vessel  on  the  living  subject, 
and  his  views  in  relation  to  it  having  been  wholly 
derived  from  speculation,  and  the  descriptions  of 
the  operations  published  by  those  who  had  per- 
formed them,  offer  for  him  a sufficient  apology. 
As  I am  persuaded  that  nothing  tends  more 
to  retard  the  advancement  of  surgery,  than  the 
exaggeration  of  difficulties,  which,  if  they  do 
exist,  are  easily  surmounted,  I consider  it  my 
duty,  so  far  as  my  own  experience  will  enable  me, 
to  assist  in  their  removal. 

One  of  the  difficulties  which  has  been  particu- 
larly insisted  upon,  by  most  of  those  who  have 
tied  the  carotid  artery,  is  the  alternate  swell  and 
collapse  of  the  internal  jugular  vein.  '‘During 
inspiration  it  falls  collapse,  but  during  expira- 
tion it  swells  out  full  and  tense , covering  al- 
most completely  the  artery.  The  transitions 
from  emptiness  to  fullness  are  so  rapid,  that 
sufficient  time  is  not  allowed  to  detach  it  from 
the  carotid So  powerful  an  impression  did 
this  and  similar  overcharged  descriptions  of 
the  state  of  the  vein,  in  relation  to  the  artery, 


APPENDIX. 


457 


make  on  my  mind,  that  I confess,  when  I was  first 
called  on  to  tie  the  carotid,  I proceeded  to  the 
performance  of  the  operation  with  painful  feel- 
ings of  uncertainty  and  doubt,  such  as  I had  never 
experienced  on  any  previous  occasion.  I was 
perfectly  acquainted  with  the  situation  of  the 
vessel;  I had  in  hundreds  of  instances,  with  a 
single  sweep  of  the  scalpel,  exposed  it  to  view 
on  the  dead  body,  and  its  most  minute  connexions 
were  familiar  to  my  mind.  Still  this  knowledge 
was  not  sufficient  to  inspire  that  confidence,  which 
alone  can  give  firmness  and  decision  to  the  ope- 
rator. The  jugular  vein  swelling  out  so  as  to 
cover  the  artery  must  be  in  an  unnatural  situ- 
ation— a situation  where  it  might  be  injured 
immediately  after  the  division  of  the  platys- 
ma  myoides,  and  fascia.  Operating,  therefore, 
under  the  influence  of  this  uncertainty  as  to 
the  state  of  the  vein,  I proceeded  with  a cau- 
tion, I may  say  a timidity,  which  prevented  me 
from  executing  it  with  that  rapidity  and  dex- 
terity, for  which  my  practical  knowledge  of  anat- 
omy, should  have  fitted  me.  Instead  of  dividing 
freely  and  with  a large  incision  the  skin,  platysma 
myoides,  and  fascia,  the  wound  of  the  skin  was 
small,  and  that  through  the  facia  still  smaller,  so 
that  when  the  artery  was  exposed  it  lay  deep  seat- 
ed in  a narrow  pit-like  wound,  where  it  was  im- 
possible to  detach  it  from  its  connexions.  Indeed, 
finding  it  difficult  to  do  this,  and  satisfied  that 
58 


,458 


APPENDIX. 


there  was  no  swelling  of  the  vein  which  could 
at  all  endanger  its  safety,  I made  a free  dilation 
of  the  wound,  and  then  with  facility,  secured  the 
artery.  This  operation  occupied  nearly  eight 
minutes  in  its  performance.  In  the  next  case 
where  I had  occasion  to  perform  the  same  opera- 
tion, from  erroneous  impressions  as  to  the  state  of 
the  vein  having  been  corrected,  I accomplished  it 
in  less  than  three  minutes. 

I have  been  particular  in  this  statement,  and 
feeling  persuaded  that  a confession  of  our  difficul- 
ties and  doubts  will  advance,  more  than  a history 
of  our  successes,  the  science  which  we  cultivate, 
I have  not  hesitated  to  speak  openly  of  my  own 
fears  and  misgivings. 

Mr.  Burns  seems  to  consider,  that  the  termina- 
tion of  the  thoracic  duct  will  be  in  danger,  if  uthe 
operation  be  performed  loir  in  the  neck  on  the  left 
side.”  This  fear,  I conceive,  is  altogether  ground- 
less. The  duct,  it  is  true,  in  its  passage  from  the 
chest,  does  lie  behind  the  left  carotid;  but,  before 
that  vessel  has  reached  the  lowest  situation  in  the 
neck,  where  it  would  be  possible  to  secure  it 
with  a ligature,  the  duct  has  separated  from  it, 
and  passed  outwards  to  reach  the  point  of  its  ter- 
mination. As  to  injury  of  the  nervous  superficialis 
cordis,  this  can  only  happen  where  the  operator 
is  so  awkward  as  to  destroy  the  posterior  wall  of 
the  cervical  sheath.  Should  it,  however,  happen, 
I confess  I should  not  apprehend  those  alarming 


APPENDIX. 


459 


consequences  which  some  have  anticipated.  It 
will,  by  minute  dissection,  be  discovered,  that  the 
nervous  superficialis  cordis  is  joined  by  numerous 
small  nerves  sent  off  from  the  lower  cervical  gan- 
glion, so  that  even  allowing  that  the  nerve  was 
destroyed  above  this  point,  there  can  be  little 
doubt  but  that  through  the  medium  of  these 
branches  derived  from  the  parent  trunk,  its  func- 
tions would  still  continue  to  be  performed. 


Note  D. — p.  286. 

The  method  recommended  by  Mr.  Cheselden, 
for  removing  enlarged  tonsils  by  ligature,  is  one 
of  great  difficulty  in  its  performance,  and  were 
there  no  other  way  in  which  it  could  be  em- 
ployed, I should,  without  hesitation,  subscribe  to 
the  justness  of  Mr.  Burns’  observations,  and 
give  a preference  to  the  knife  in  every  instance. 
The  application  of  a wire  around  the  base  of  an 
enlarged  tonsil,  is,  however,  an  operation  which 
may  be  executed  with  the  greatest  facility,  and 
should  obtain,  in  my  opinion,  a decided  preference 
over  every  other  plan  of  operating.  Dr.  Physick, 
who  is  justly  distinguished  for  his  eminence  in  his 
profession,  has  published  in  the  first  number  of  the 


460 


APPENDIX. 


Medical  and  Physical  Journal  of  Philadelphia,  an 
account  of  the  method  of  using  the  wire  and  double 
canula  in  the  removal  of  schirrous  tonsils,  which, 
as  it  explains  the  different  steps  of  the  operation, 
I shall  take  the  liberty  of  transcribing. 

“The  double  canula  I employ  is  about  four 
inches  long,  with  short  arms  soldered  on  its  sides, 
near  one  end  of  the  instrument,  at  right  angles  to 
it.  Through  the  canula  I next  pass  a double 
iron  wire,  and  fasten  one  of  its  extremities  round 
one  of  the  arms  of  the  instrument,  leaving  the 
other  free  and  projecting  five  or  six  inches.  This 
enables  me  to  increase  or  diminish  the  size  of  the 
noose,  formed  by  the  doubling  of  the  wire,  at 
pleasure.  The  selection  of  a proper  piece  of  wire 
I consider  of  much  importance.  It  should  be 
tough  and  flexible,  formed  of  soft  pure  iron,  hav- 
ing firmness  enough  to  allow  of  its  being  pushed 
backwards  and  forwards  in  the  canula,  without 
bending  too  easily,  so  that  the  noose  may  be  en- 
larged or  diminished.  It  should  also  have  suffi- 
cient firmness  to  allow  of  a little  lateral  pressure, 
otherwise  the  noose  cannot  be  pressed  down  so 
certainly  on  the  base  of  the  tumour.  The  wire  I 
use  is  about  one  twenty-fourth  of  an  inch  in  dia- 
meter, or  perhaps  rather  less. 

“It  is  moreover  necessary  to  be  provided  with 
a flat  pair  of  pliers,  to  take  hold  of  and  move  the 
wire  conveniently.  These  instruments  being  pre- 
pared, the  noose  formed  by  the  doubling  of  the 


APPENDIX. 


461 


wire  projecting  beyond  the  end  of  the  instrument, 
is  10  be  made  large  enough  to  pass  easily  over  the 
enlarged  tonsil,  and  should  be  bent  a little  to  one 
side,  in  order  that  it  may  more  easily  be  pushed 
down  upon  the  base  of  the  tumour. 

“The  patient  is  to  be  seated  opposite  a window, 
and  his  tongue  must  be  held  down  by  an  assistant, 
with  the  handle  of  a large  spoon,  or  with  a spa- 
tula. The  surgeon  is  then  to  slip  the  noose  over 
the  tonsil,  and  down  to  its  base,  taking  care  not 
to  include  the  uvula,  which,  when  the  swelling  is 
large,  is  apt  to  be  in  the  way.  The  wire  is  then 
to  be  drawn  sufficiently  to  fix  it  loosely  on  the 
part,  and  the  surgeon  is  to  satisfy  himself,  by  an 
attentive  inspection,  that  it  is  properly  applied. 
This  being  accomplished,  the  wire  is  to  be  taken 
hold  of  with  the  pliers,  and  drawn  through  one 
side  of  the  canula,  so  as  to  secure  it  at  once  on  the 
base  of  the  tonsil  as  firmly  as  possible,  and  then 
to  fasten  it  on  the  arm  of  the  instrument,  and 
thereby  prevent  all  entrance  of  fresh  blood  into 
the  tumour.  This  method  of  stopping  the  circu- 
lation of  blood  in  the  swelling,  necessarily  occa- 
sions severe  pain  at  the  moment;  but  the  severity 
of  it  soon  ceases. 

“On  examining  the  tonsil  after  a few  minutes, 
its  colour  will  be  observed  to  be  changed  to  a 
deep  purple,  or  almost  black,  and  its  surface 
smooth  and  polished,  owing  to  the  exterior  mem- 
brane being  stretched. 


462 


APPENDIX. 


“It  has  hitherto  been  my  custom  to  allow  the 
instrument  to  remain  thus  applied  for  twenty  four 
hours,  with  the  view  of  destroying  completely  the 
life  of  the  enlarged  gland.  I am,  however,  of 
opinion,  that  a much  shorter  time  would  be  suffi- 
cient, as  eight  or  twelve  hours,  which  I propose 
soon  to  ascertain.  After  having  destroyed  the 
life  of  the  swelling  by  the  above  means,  the  next 
step  of  the  operation  is  the  removal  of  the  instru- 
ment, which  is  very  easily  accomplished,  in  the 
following  manner.  Take  a firm  hold  of  the  end 
of  the  canula  projecting  from  the  mouth,  then  dis- 
engage the  wire  on  one  side  from  the  arm  of  the 
instrument;  straighten  it,  and  with  the  pliers  push 
a small  portion  of  it  back  through  the  canula,  and 
repeat  this  until  the  noose  is  so  much  enlarged  as 
to  slip  off  the  tonsil. 

“The  operation  is  now  completed;  the  tumour 
appears  shrivelled  and  of  a dull  white  colour;  the 
patient  suffers  no  pain;  the  inflammation  is  mo- 
derate, and,  after  a few  days,  the  dead  parts  are 
separated  and  thrown  off,  either  entire  or  in  frag- 
ments, which  are  sometimes  spit  out,  sometimes 
swallowed.  Until  the  separation  is  completed  the 
breath  is  somewhat  offensive.  I have  never  had 
any  trouble  with  the  small  ulcer  remaining  after 
the  separation  of  the  tumour.  It  has  healed  so 
rapidly  as  generally  to  escape  notice.’7* 

* Philadelphia  Medical  and  Physical  Journal,  p.  18,  et  seq. 


APPENDIX. 


463 


Another  plan  for  applying  the  ligature  has  been 
recommended  lately  by  Mr.  Chevalier;*  but  the 
one  just  described,  whether  viewed  in  relation  to 
its  simplicity  or  certainty,  is  decidedly  superior 
to  it. 


Note  E. — p.  352. 

Mr.  Burns  observes,  in  speaking  of  the  cure  of 
aneurism  by  anastomosis,  that  “any  attempt  to 
cure  this  disease  by  ligature  of  the  arteries  which 
support  it,  is  entirely  out  of  the  question.  Mr. 
John  Bell  strenuously  argues  the  necessity  of  cut- 
ting out  all  the  diseased  parts,  and  in  equally  de- 
cided terms  reprobates  any  interference  when  we 
judge  this  to  be  impracticable. ” From  these  ob- 
servations it  would  appear,  that  at  the  time  when 
Mr.  Burns’  work  was  published,  anastomosing 
aneurisms  were  considered  as  incurable,  unless 
when  placed  in  situations  where  they  could  be 
completely  extirpated,  or  if  this  was  impossible, 
where  we  had  the  “power  to  use  very  firm  pres- 
sure ” on  all  the  morbid  parts  which  remained. 
As  there  are  many  cases  of  this  disease  in  which 
it  is  neither  practicable  to  extirpate  the  whole  of 
the  morbid  parts,  nor  to  apply  “firm  pres- 
sure ” to  those  which  remain;  if  the  doctrine 
delivered  by  Mr.  Burns  and  Mr.  Bell,  was  cor- 


* Metltco  Chirurgical  Transactions,  vol.  iii.  p.  SO. 


464 


APPENDIX. 


rect,  patients,  so  situated,  must  be  left  to  their 
fate.  Fortunately,  however,  the  progress  of 
science  has  shown  the  fallacy  of  those  opin- 
ions, and  has  demonstrated,  that  by  tying  the 
great  artery,  passing  to  the  morbid  parts,  we 
can  cure  an  anastomosing  aneurism  nearly  with  the 
same  certainty  as  a common  aneurism.  To  Mr. 
Travers,  a gentleman  whose  name  is  familiar  to 
every  member  of  the  profession,  we  are  indebt- 
ed for  this  improvement  in  the  treating  of  aneu- 
rism by  anastomosis.  In  a case  where  a tumour 
of  this  kind  was  situated  in  the  orbit,  he  tied 
with  complete  success  the  common  carotid  ar- 
tery of  the  same  side.*  The  same  operation 
has  since  been  performed  by  Mr.  Dairy  m pie,  f 
for  the  cure  of  an  anastomosing  aneurism,  which 
in  its  situation  and  character  exactly  resembled 
the  one  described  by  Mr.  Travers,  and  the  liga- 
ture of  the  carotid  was  attended  with  the  same 
success. 

In  a case  of  the  same  disease,  situated  in  the 
branches  of  the  internal  maxillary  artery,  which 
came  under  my  own  observation,  I had  an  op- 
portunity of  testing  and  proving  the  justness  of 
the  views  taught  by  Mr.  Travers.  As  this  case 
is  one  of  great  interest  I shall  transcribe  it. 

“Mr.  C.  C.  aged  eighteen  years,  consulted  me 
the  sixth  of  April,  1821,  on  account  of  a great 


* See  Medico  Chirugical  Transactions,  vol.  ii. 


t Ibid.  vol.  vi. 


APPENDIX. 


465 


tumefaction  of  the  left  side  of  the  face.  As  the 
history  of  the  origin  and  progress  of  the  dis- 
ease is  very  ably  detailed  in  two  letters,  which  I 
have  received  from  my  patient  after  his  return 
home,  I shall  introduce  them,  as  containing  a more 
distinct  account  of  the  complaint  than  any  I could 
furnish, 

“George  Town,  May  30th,  1821. 

“Dear  Sir, 

“Agreeably  to  my  promise,  I now  send  you  a 
detailed  account  of  the  disease  in  my  face,  from 
its  commencement  down  to  the  period  of  the  late 
operation.  My  own  recollections  have  been  as- 
sisted by  my  nurse,  who  has  been  in  the  family 
during  the  whole  course  of  the  disease,  and  whose 
situation,  whilst  I remained  at  home,  afforded  her 
a better  opportunity  than  others  of  observing  the 
circumstances  attending  it. 

“To  the  best  of  my  recollection,  the  disease 
first  appeared  in  the  cheek  early  in  the  summer 
of  1813,  I being  then  ten  years  of  age;  about  the 
end  of  the  season,  it  began  to  make  its  appearance 
about  the  temple,  when  it  first  excited  the  alarm 
of  my  friends.  After  this  time,  I paid  several 
visits  to  Philadelphia,  for  the  purpose  of  con- 
sulting the  professional  gentlemen  of  that  city, 
and  I recollect  these  were  for  some  time  in  doubt 
before  they  determined  the  disease  to  be  a poly- 
pus. At  one  time  they  decided  that  it  was  not, 
59 


466 


APPENDIX. 


and  perhaps  their  final  determination  was  in- 
fluenced by  this  circumstance,  I told  them,  and 
with  much  confidence  too,  that  I believed  the  dis- 
ease to  have  originated  in  the  nostril.  As  the 
disease  at  first  gave  me  no  uneasiness,  and  occu- 
pied little  of  my  thoughts,  I might  readily  have 
been  mistaken  in  this  circumstance,  and  my  own 
subsequent  reflection,  as  well  as  the  opinion  of  my 
nurse,  induces  me  to  believe  that  I did  err. 

“The  period  of  the  first  operation  I do  not  re- 
member, but  its  duration  was  about  three-fourths 
of  an  hour;  and,  though  I was  able  to  walk  about 
the  same  evening,  I considered  it  more  disagree- 
able than  the  second.  The  next  operation  was  in 
the  spring  of  1815,  and  was  much  more  extensive: 
but  as  I believe  you  are  acquainted  with  its  na- 
ture, I will  not  enter  into  a detail  of  it.*  I would, 
however,  mention,  that  after  a considerable  time, 
1 fainted  from  loss  of  blood,  which  forced  them  to 
stop  the  operation.  The  doctors  hoped  that  they 
had  rid  me  of  the  disease,  and  for  some  time  there 

* Both  of  the  operations  to  which  Mr.  C.  refers,  were  performed  under 
the  erroneous  impression  that  the  disease  w as  a polypus.  T he  first  was 
executed  with  a ligature,  and  forceps  introduced  through  the  nostril.  The 
surgeon  at  this  time  entertaining  the  belief  that  the  disease  was  confined  to 
the  nostril.  The  cheek,  however,  beginning  to  swell  shortly  afterwards,  it 
was  supposed  that  the  polypus  had  originated  from  the  antrum,  and  ail 
operation  was  performed  with  a view  of  extirpating  it.  The  operation 
consisted  in  removing  with  the  trephine,  the  anterior  wall  of  the  antrum, 
and  thus  having  exposed  the  tumour,  an  attempt  was  made  to  cut  it  out. 
The  bleeding  w as,  however,  such  as  soon  to  put  a stop  to  the  operation.  T he 
quantity  of  blood  lost  during  it  was  very  great,  and  the  patient  was  so 
enfeebled  as  to  he  obliged  to  remain  in  bed  for  some  weeks  afterwards. 


APPENDIX. 


467 


was  a diminution  of  the  cheek  and  an  absence  of 
the  disease  in  the  nose.  These  favourable  ap- 
pearances were  of  short  duration;  the  disease 
reappeared,  and  gradually  increased,  without  the 
application  of  any  remedy,  until  the  commence- 
ment of  the  last  fall.  I was  induced  a short  time 
previously,  to  consult  a person  who  had  the 
reputation  of  being  successful,  in  treating  several 
novel  cases;  and  as  his  remedies  appeared  sim- 
ple, and  he  appeared  confident,  I determined  to 
follow  his  advice.  Having  been  foolish  enough 
to  submit  to  his  directions,  the  hope  of  relief  in- 
duced me  to  continue  that  submission  when  his 
treatment  became  more  severe;  and  thus  I sub- 
jected myself  to  much  trouble,  pain,  and  expense, 
without  reaping  any  good  fruits. 

“I  do  not  remember  any  violent  bleedings  pre- 
viously to  the  first  operation;  and  though  1 re- 
collect having  experienced  them  between  this 
and  the  second,  yet,  from  the  lapse  of  time,  I 
have  a very  indistinct  idea  of  the  circumstances 
attending.  - It  was  after  the  second  operation 
that  they  were  most  frequent  and  most  violent. 
In  the  summer  of  1817,  they  became  so  frequent 
as  to  alarm  my  friends.  If  I overheated  myself, 
or  suffered  a slight  blow  on  the  nose,  or  was 
jarred,  my  nose  would  bleed  violently;  sometimes 
it  would  bleed  spontaneously.  In  two  days  (in 
three  bleedings)  it  bled  so  very  copiously,  from  my 
having  blown  my  nose,  that  I was  confined,  from  its 


468 


APPENDIX. 


effects,  for  some  days  after.  The  blood  I would 
lose  at  each  of  these  bleedings,  would  frequently 
measure  a pint,  and  sometimes  would  exceed  this 
quantity:  it  would  stream  out  most  violently,  and 
all  exertions  to  stop  it  appeared  to  have  no  good 
effect.  In  the  summer  of  1818,  I was  at  college, 
and  the  bleedings  were  then  more  violent  than 
ever.  Having  no  person  with  whom  I could  con- 
sult, I felt  much  alarm  at  my  situation,  and  it 
must  have  been  very  dangerous.  Very  frequent- 
ly, whilst  I would  be  sitting  quietly  in  my  room, 
(I  was  careful  to  use  as  little  motion  as  possible,) 
the  blood  would  gush  forth  in  torrents,  I having 
no  previous  notice  that  it  was  coming.  Especial- 
ly during  the  warmest  part  of  the  season,  I was 
obliged  to  restrict  myself  very  much  in  exercise; 
a slight  exertion,  a very  short  walk  in  the  heat  of 
the  day,  was  generally  followed  by  a violent 
bleeding.  At  one  time,  I was  obliged  to  debar  my- 
self entirely  of  exercise;  a walk  of  twenty  yards 
in  the  sun  has  produced  a violent  bleeding. 
Sometimes  I had  warning  of  a violent  bleeding 
by  a slight  spontaneous  one,  and  in  this  case,  I gen- 
erally took  a dose  of  salts,  which  had  the  effect 
of  retarding  it.  Sometimes,  though  not  so  violent- 
ly, the  blood  would  descend  through  the  orifice  to 
the  mouth,  as  if  unable  to  obtain  a vent  in  the 
usual  way.  I have  remarked  this  circumstance 
in  the  bleedings,  that  they  were  most  violent  and 
frequent  in  the  warmest  weather;  in  the  winter,  I 


APPENDIX. 


469 


seldom  bled  beyond  what  many  persons  in  health 
are  subject  to.  Since  1818,  I do  not  remember 
any  violent  bleedings  until  the  last  winter.  If 
there  have  been  any,  they  were  very  rare.  Dur- 
ing the  last  winter  I had  two  or  three  that  were 
pretty  copious,  but  they  were  all  caused  by  fol- 
lowing the  prescriptions  of  the  German  doctor. 

“Having  delayed  writing  for  some  time,  I now 
address  you  in  such  haste  as,  perhaps,  to  omit 
some  points  on  which  you  wish  information. 
Should  this  be  the  case,  I will  gladly  give  you 
any  further  information  in  my  power. 

With  much  respect, 

I remain,  dear  sir, 

Your  most  obedient  servant, 

C.  C. 

“George  Town , June  4,  1821. 

“Dear  Str, 

“In  the  haste  of  my  former  communication,  I 
omitted  some  particulars  which  it  may  be  agreea- 
ble to  you  to  hear. 

The  left  cheek,  at  its  usual  temperature,  was 
always  warmer  than  the  other,  and  was  much 
more  easily  affected  by  exposure.  So  delicate 
was  it,  that  when  obliged  to  expose  myself  to  the 
summer’s  sun,  if  the  rays  fell  in  that  direction, 
I was  obliged  to  cover  the  affected  cheek;  and  I 
have  frequently  suffered  inconvenience  from  lying 
on  it. 


470 


APPENDIX. 


“There  was  also  in  this  cheek  a very  peculiar 
feeling,  which  extended  itself  over  the  left  half 
of  the  upper  jaw.  I am  at  a loss  to  describe  this 
peculiarity;  but  it  has  now  entirely  disappeared, 
and,  to  the  feeling,  the  parts  are  as  well  as  those 
corresponding  on  the  opposite  side  of  the  face. 

“The  fine  air  of  our  town  has  worked  a miracle 
in  my  favour;  my  strength  is  returning  very  fast, 
and  both  neck  and  cheek  are  doing  very  well. 

With  the  highest  respect, 

I am,  your  obedient  servant, 

C.  C. 

“The  tumour  of  the  cheek  was  at  the  time  I saw 
Mr.  C.  very  large  its  central  point  occupied  the 
situation  of  the  antrum  higmorianum;  but  the 
walls  of  this  cavity  having  been  destroyed,  it 
passed  from  thence  in  every  direction  upwards, 
into  the  orbit,  protruding  the  eye,  nasally  it  pas- 
sed into  the  nostril  of  the  left  side,  which  it  com- 
pletely filled,  and  pressing  on  the  septum-narium, 
it  gave  a general  character  of  distortion  to  the  nose. 
This  tumour  was,  however,  most  prominent  in  a 
direction  outwards.  The  second  operation  hav- 
ing removed  the  anterior  wall  of  the  antrum  in 
this  direction,  there  was  nothing  opposed  to  its 
passage,  except  the  small  facial  muscles;  and 
their  forces,  although  they  might  have  a tenden- 
cy to  prevent  its  direct  growth  outwards,  could 
have  little  effect  in  restraining  it  from  growing  in 


APPENDIX. 


471 


a direction  outwards  and  backwards.  The  sym- 
metry of  the  left  side  of  the  countenance  was 
completely  destroyed.  The  tumour,  which  in  size 
was  nearly  equal  to  the  head  of  a new  born  child, 
extended  from  the  left  margin  of  the  nose,  to  the 
line  which  is  marked  on  the  neck  by  the  tracheal 
margin  of  the  sterno-eleido-mastoideus  muscle. 
When  the  disease  was  examined  as  it  appeared 
in  the  nostril,  the  first  impression  produced,  was 
that  it  was  a polypus  of  the  antrum.  This  im- 
pression could  not,  however,  after  an  attentive 
examination  be  entertained;  there  is  in  all  po- 
lypi, an  expression,  if  I may  use  the  term,  alto- 
gether peculiar;  their  vitality  is  of  a low  grade, 
and  their  imperfect  organization  is  so  marked  as 
to  enable  us  to  distinguish  them  from  all  other  af- 
fections. Had  it,  however  been  otherwise,  and 
had  we,  from  the  examination  of  the  tumour  as  it 
appeared  in  the  nostril,  been  led  to  adopt  an  erro- 
neous opinion  as  to  its  true  nature,  this  must  have 
been  corrected  by  pressing  the  tumour  betwixt 
the  fingers,  one  having  been  introduced  into  the 
mouth,  and  another  placed  on  its  external  sur- 
face; as  thus  examined,  the  distinguishing  char- 
acter of  anastomosing  aneurism  was  at  once  de- 
tected, that  peculiar  pulsatory  throbbing  which 
characterizes  them  from  all  other  affections,  being 
distinctly  felt.  The  opinion  I delivered  to  my 
very  intelligent  friend,  Mr.  Hayden,  was,  that  the 
disease  was  an  anastomosing  aneurism,  situated  in 


472 


APPENDIX. 


the  terminating  branches  of  the  internal  maxillary 
artery;  that  the  disease  having  begun  behind  the 
tuber  maxillare  had  first  entered  the  nostril,  in- 
ducing the  belief  that  polypus  had  formed  there; 
that  from  thence  it  had,  by  destroying  the  poste- 
rior wall  of  the  antrum  higmorianum  passed  into 
and  occupied  that  cavity;  that  enlarging,  it  had 
protruded  and  rendered  prominent  the  external 
wall  of  the  antrum,  which  was  by  the  surgeon  re- 
moved, with  the  view  of  extirpating  it.  under  the 
impression  that  the  polypus  had  entered  the  cave 
of  the  cheek. 

“Mr.  Hayden,  on  receiving  this  statement,  as- 
sured me  that  from  the  examination  which  he  had 
made  when  consulted  by  Mr.  C.  at  Washington 
City,  he  had  believed  that  the  disease  was  a com- 
mon aneurism;  but  as  this  opinion  was  opposed  to 
the  one  given  by  the  eminent  surgeons  who  had 
performed  the  two  operations  upon  it,  he  had 
begged  Mr.  C.  to  visit  Baltimore  and  consult  me; 
and  anxious  that  his  patient  might  hear  my  opin- 
ion unbiassed  by  any  observations  of  his,  he  had 
determined  not  to  state  his  suspicions  until  I had 
delivered  to  Mr.  C.  my  opinion. 

“Had  I from  an  examination  found  any  difficulty 
in  deciding  on  the  nature  of  the  disease,  recalling 
to  recollection  the  facts  of  its  history,  I could  not 
have  hesitated.  Its  progress,  the  suspicious  tem- 
perature of  the  tumour,  but  above  all,  its  frequent 


APPENDIX. 


473 


and  tremendous  haemorrhage,  were  symptoms 
which  could  not  have  been  found  attendant  on  any 
other  affection.  As  to  the  proper  plan  of  treat- 
ment, there  could  be  with  bold  and  intelligent  sur- 
geons but  one  opinion.  Mr.  C.  held  his  life  on  a 
most  uncertain  tenure,  every  hour  he  was  in  emi- 
nent jeopardy  of  losing  it,  and  every  evening,  as 
he  closed  his  eyes  in  sleep,  a bleeding  occurring 
during  his  slumbers,  might  have  placed  the  cold 
seal  of  death  upon  his  eyes,  and  prevented  them 
from  ever  again  beholding  the  light  of  the  morn- 
ing. 

“To  prove  that  his  state  was  as  dangerous  a one 
as  we  have  represented,  it  is  only  necessary  to 
state,  that  about  two  months  before  Mr.  C.  came 
to  Baltimore  the  blood  gushed  in  such  a torrent 
from  his  nostril,  as  to  render  him  insensible  before 
he  could  reach  the  bell,  and  he  was  only  acciden- 
tally discovered  sometime  afterwards,  in  a state  of 
syncope,  by  a member  of  his  family  who  happened 
to  enter  his  chamber.  The  operation  of  extirpat- 
ing the  tumour  of  vessels  was  out  of  the  question. 
Could  we  even  have  flattered  ourselves  that  our 
patient  could  have  survived  the  great  effusion  of 
blood  which  must  have  followed  cutting  into  it;  it 
was  impossible  to  expect  that  a substance  so  soft 
and  pliable,  would  not  have  passed  into  some  of 
the  small  osseous  recesses  situated  in  the  facial 
bones,  and  would  there  have  eluded  our  search, 
and  formed  a root  from  which  the  disease  would 
(50 


474 


APPENDIX. 


speedily  have  been  reproduced.  The  only  opera- 
tion by  which  we  could  hope  to  benefit  Mr.  C. 
was  that  of  tying  the  great  carotid  artery,  and 
th  us  throwing  the  circulation  of  the  facial  arte- 
ries of  that  side  into  new  channels,  and  by  this 
means  taking  off  its  pressure  from  those  branches 
which  were  diseased.  Reasoning  upon  general 
principles,  we  were  entitled  to  hope  this  result. 
And  bringing  to  mind  the  success  whieh  had  fol- 
lowed the  ligature  of  the  carotid,  in  the  cases  of 
anastomosing  aneurism  recorded  by  Messrs.  Tra- 
vers and  Dalrymple,  the  justness  of  our  hopes 
were  confirmed.  There  was,  however,  more  to 
be  apprehended  in  the  case  of  Mr.  C.  than  in  the 
ones  alluded  to.  From  its  situation,  and  from  its 
long  continuation  and  great  size,  very  considerable 
disease  in  the  parts  surrounding  it  was  to  be  ap- 
prehended. The  ligature  of  the  artery  would 
destroy  the  aneurismal  character  of  the  tumour; 
but  its  irritation  had  produced  so  much  thickening 
and  disease  in  the  surrounding  parts,  that  it  was 
not  improbable  that  they,  receiving  a sufficiency 
of  blood  for  their  support,  might  continue  to  in- 
crease, and  finally,  by  ulceration  and  the  assump- 
tion of  a specific  morbid  action,  terminate  in  the 
death  of  our  patient.  As  Mr.  C.  possessed  a mind 
of  a very  superior  order,  I did  not  hesitate  to  make 
him  fully  acquainted  with  every  particular  of  his 
case.  I informed  him,  that  in  my  opinion,  an  opera- 
tion ought  to  be  performed,  but,  at  the  same  time 


APPENDIX. 


475 


requested  him,  on  account  of  the  very  different 
view  which  had  been  taken  of  his  case  by  the  pro- 
fessional gentlemen  of  Philadelphia,  to  consult,  be- 
fore submitting  to  it,  my  distinguished  friend  and 
colleague  Dr.  Davidge.  Having  seen  that  gen- 
tleman and  obtained  from  him  an  opinion  which 
coincided  in  every  particular  with  the  one  which 
I had  before  delivered;  Mr.  C.  with  the  most  manly 
fortitude,  at  once  consented  to  the  performance  of 
an  operation. 

“The  operation  was  performed  in  the  way  it  is 
usually  executed.  Immediately  after  its  per- 
formance, the  appearance  of  the  tumour,  as  it 
presented  itself  in  the  nostril,  became  remarkably 
changed;  just  before  it  seemed  distended,  even  to 
bursting;  but  so  soon  as  the  direct  circulation 
was  removed,  its  distension  was  destroyed,  and  it 
became  shrivelled  on  its  surface.  The  pulsatory 
movement,  which  could,  previous  to  the  operation, 
be  easily  discovered  in  the  body  of  the  tumour, 
could  not,  after  it  was  executed,  be  detected. 
As  nothing  remarkable  occurred  during  the  pro- 
gress of  the  cure,  it  is  quite  unnecessary  to  give 
a detailed  account  of  it.  It  is  sufficient,  in  regard 
to  the  treatment,  to  observe,  that  with  the  view 
of  taking  from  the  force  of  the  circulation,  and  of 
preventing  the  spreading  of  the  inflammation  from 
the  wound  to  the  neighbouring  parts,  free  deple- 
tion by  means  of  the  lancet  and  purgatives  was 
adopted.  And  in  respect  to  the  appearance  of 


476 


APPENDIX. 


the  tumour,  it  is  only  necessary  to  state,  that 
there  was  a daily  improvement  in  the  expression 
of  the  countenance.  The  absorbents  fulfilled  their 
duties  with  much  more  energy  than  could  have 
been  expected;  the  tumefaction  entirely  disap- 
peared; the  malar  bone,  and  zygoma  which  were 
completely  buried  in  the  tumour,  as  it  was  ab- 
sorbed became  evident,  and  the  whole  character 
of  the  countenance  became  altered. 

“The  deformity,  in  so  far  as  it  was  produced  by 
the  aneurismal  tumour,  was  completely  removed 
before  Mr.  C's  return  home;  but,  as  the  tumour  had 
produced  an  enlargement  and  forcing  of  the  bones 
of  tbe  side  of  the  face  outwards,  and  as  their  ab- 
sorption is  a slow  process,  the  side  of  the  face 
where  the  disease  had  been  seated  continued  some- 
what more  enlarged  than  the  opposite  side.  The 
absorption  is  however  going  on  steadily,  and  there 
is  every  reason  to  hope,  that  by  the  employment 
of  pressure,  the  natural  symmetry  of  the  counte- 
nance will  be  speedily  restored. 

* It  is  now  two  years  and  a half  since  the  operation  was  performed  on 
Mr.  C.  and  during  the  whole  of  this  period,  no  symptom  has  manifested 
itself  which  could  lead  to  the  suspicion  that  the  disease  was  about  to  re- 
turn. On  the  contrary, the  improvement  in  his  appearance  has  been  re- 
gularly progressive,  and  he  has  enjoyed  the  most  perfect  and  uninter- 
rupted good  health.  At  present  the  deformity  is  so  trifling  as  to  be  hardlv 
perceptible. 


APPENDIX. 


477 


Note  F. — p.  385. 

There  have  been,  perhaps,  no  operations  per- 
formed, which  have  been  so  unfortunate  in  their 
results,  as  those  executed  for  the  removal  of 
tumours  from  the  antrum  maxillare.  Buried 
amongst  the  bones  of  the  face,  before  they  have 
increased  to  such  a size  as  to  attract  either  the 
attention  of  the  patient  or  his  surgeon,  they  have, 
in  most  cases,  passed  into  numerous  recesses, 
from  which  it  was  impossible  to  remove  every 
diseased  part.  As  these  affections  are  far  from 
being  uncommon,  I had  devoted  considerable  at- 
tention to  their  study,  and  had,  from  reasoning  on 
general  principles,  formed  certain  conclusions  as 
to  the  best  method  of  proceeding  to  their  removal, 
the  correctness  of  which  I think  has  been  con- 
firmed, by  the  result  of  some  cases  where  these 
principles  have  been  adopted. 

We  are  well  aware,  that  the  vitality,  or  capa- 
city for  action  of  a part,  is  proportioned  to  its 
vascularity.  We  know  also,  that  if  we  excite  a 
part  to  the  performance  of  an  action  beyond  its 
power,  that  as  a necessary  consequence,  its  vital- 
ity is  destroyed,  it  sloughs,  and  is  thrown  off. 
These  principles,  which  are  universally  admit- 
ted, constitute  the  basis  of  a theory  which  has 
dictated  the  plan  of  treatment,  I have  considered 


478 


APPENDIX. 


the  most  advisable  to  be  pursued  in  cases  of  tu- 
mours in  the  antrum,  and  which  has,  where  exe- 
cuted in  the  only  cases  I have  known,  proved 
successful. 

When  in  Raltimore  on  a visit,  in  the  month  of 
July,  1820,  before  my  election  to  the  Chair  of 
Surgery  in  the  University  of  Maryland,  1 was  re- 
quested by  Dr.  Baker,  to  visit  a James  Under- 
wood, who  was  affected  with  a tumour  of  the  an- 
trum. The  disease  had  proceeded  to  a very  great 
extent.  The  walls  of  the  cavity,  from  which  it 
had  originated,  were  burst  asunder.  It  passed 
down  through  the  osseous  palate,  so  as  to  fill  the 
mouth  and  to  push  backwards  the  velum  pendu- 
lum palati,  and  outwards  so  as  completely  to  dis- 
figure the  cheek  of  that  side,  forming  there  a 
large  and  unseemly  fungus.  I particularly  stated 
at  this  time,  to  Drs.  McDowell,  Revere,  and  Hall, 
that,  as  the  disease  manifested  so  many  characters 
of  its  being  of  a specific  nature,  I did  not  feel  my- 
self warranted  to  press  the  patient  to  submit  to 
an  operation,  as  no  man,  I conceived,  could  en- 
sure its  being  successful;  at  the  same  time,  I ex- 
plicitly declared,  that  if  he  would  be  willing  to 
submit  to  one  without  an  assurance  of  certain 
success,  I was  perfectly  ready  to  operate. 

I heard  nothing  more  of  the  case  until  the  fol- 
lowing October,  when  I was  politely  invited  by 
Dr.  Gillingham  to  be  present  at  the  operation 
which  he  proposed  to  perform  on  the  same  patient. 


APPENDIX. 


479 


There  were  in  the  chamber,  where  the  opera- 
tion was  to  be  performed  a great  number  of  pro- 
fessional gentlemen,  and  I there  openly  and  freely 
expressed  my  views  as  to  the  operation  which  I 
thought  ought  to  be  performed.  To  my  friend 
Dr.  Davidge,  who  was  standing  with  Dr.  Ja- 
meson, in  one  part  of  the  room,  I explained 
particularly  my  sentiments,  and  insisted  on  the 
propriety  of  tying  the  common  carotid  artery  of 
the  side  on  which  the  tumour  was  situated,  before 
any  attempt  was  made  to  extirpate  it.  I did  not 
apprehend  that  during  the  operation  of  its  remo- 
val, the  patient  would  be  subjected  to  a danger- 
ous haemorrhage,  and  that  this  was  to  be  guard- 
ed against,  by  the  ligature  of  the  artery.  An- 
other and  in  my  opinion,  a much  more  impor- 
tant object,  was  to  be  gained  by  it.  The  vas- 
cularity and  consequent  vitality  of  the  tumour 
was  much  inferior  to  that  of  the  parts  with 
which  it  was  connected,  and  as  they,  and  like- 
wise any  portions  of  the  diseased  mass,  which 
it  might  be  impossible  to  remove  with  the  knife, 
would  by  the  operation  be  brought  into  a state 
of  inflammation,  and  increased  action.  I hop- 
ed by  diminishing  the  circulation  of  blood  through 
them  that  the  morbid  parts,  whose  power  of  action 
were  previously  weak,  would  in  the  enfeebled  state 
in  which  they  would  be  placed  by  the  ligature  of  the 
artery,  be  incapable  of  supporting  the  increased 
action  which  would  be  demanded  of  them,  and  that 


480 


APPENDIX. 


they  would  mortify  and  fall  off.  These  sentiments 
I had  stated  fully  to  Drs.  M ‘Dowell.  Revere,  and 
Hall,  when  I was  first  consulted  on  the  case,  and 
repeated  them  at  this  time  to  Dr.  Davidge  in  the 
presence  of  Dr.  Jameson. 

The  operation  for  which  the  company  had  as- 
sembled having  been  postponed,  I heard  nothing 
more  of  the  case  for  some  days  when  having  learn- 
ed that  Dr.  Gillingham  declined  interfering  in  it. 
I made  inquiries  for  the  purpose  of  getting  the 
patient  to  submit  to  the  operation,  I had  suggested. 
Having  been  informed  that  Dr.  Jameson  had 
taken  charge  of  the  case,  I,  of  course,  gave  up  all 
thoughts  of  interfering  with  it. 

Dr.  Jameson  operated  sometime  afterwards, 
tying  the  carotid  artery  and  then  removing  a part 
of  the  tumour.  Believing  it  “to  be  a case  of  tu- 
mour of  the  gums”  he  did  not  enter  the  antrum. 
This  fact  I consider  important,  as  it  tends  to  cor- 
roborate and  support  the  principles  I have  alrea- 
dy stated.  That  it  did  originate  from  the  cave  of 
the  cheek,  my  learned  colleague,  Dr.  Davidge  had 
demonstrated  in  the  presence  of  several  medical 
gentlemen,  some  months  before,  by  cutting 
through  the  palate  and  showing  the  whole  of  that 
cavity  impacted  and  filled  with  the  morbid  sub- 
stance. The  operation,  therefore,  only  removed 
a very  small  part  of  the  tumour,  and  the  removal 
of  the  rest  must  be  attributed  to  its  not  possess- 
ing power  after  the  artery  was  tied  for  the  ful- 


APPENDIX. 


481 


fihnent  of  that  action  which  it  was  called  on  to 
perform. 

The  justness  of  the  principle  which  I have 
brought  before  the  observation  of  the  profession, 
does  not,  however,  rest  on  the  success  of  this 
single  case.  My  friend,  Dr.  Davidge,  has  carried 
it  farther  than  I had  contemplated,  and,  as  it  will 
appear  from  the  following  letter,  in  so  far  as  the 
tumour  was  concerned,  with  the  happiest  result. 

“Professor  Pattison, 

“Dear  Sir, 

“In  pursuance  of  my  promise,  I transmit  to  you 
the  subjoined  account  of  the  operation,  performed 
by  me,  for  the  fungus  of  the  antrum  of  the  face. 

“On  the  third  of  April,  1823,  a negro  man,  at 
the  house  of  Mr.  Floyd,  was  put  under  my  pro- 
fessional charge;  he  laboured  under  a fungus  of 
the  antrum  of  the  left  side  of  the  face;  the  condi- 
tion of  the  body  was  hectic,  and  very  much  ema- 
ciated; the  upper  part  of  the  cheek  protruded,  and 
was  much  distorted;  the  tumour  had  destroyed  a 
considerable  portion  of  the  lower  and  external  re- 
gion of  the  superior  maxillary  bone,  and  descend- 
ed into  the  mouth.  The  finger,  by  pressing  the 
fungus  a little  to  one  side,  could  be  passed  up 
into  the  antrum. 

“The  day  precedent  to  the  operation,  a cathartic 
was  administered. 

“After  having  placed  the  patient  in  a proper 
sitting  position,  and  opposite  a good  light,  atcend- 

bi 


482 


APPENDIX. 


ed  by  several  young  professional  gentlemen,  I 
made  an  incision  of  about  three  inches  in  length, 
down  to  the  delicate  fascia,  along  the  track  of  the 
carotid  artery,  inclining  my  knife  a little  to  the 
trachea,  to  avoid  exposing  the  internal  jugular 
vein.  I then,  by  a second  cut,  exposed  the  ster- 
no-cleido-mastoideus  just  where  it  is  somewhat 
obliquely  traversed  by  the  omo  hyoideus,  in  its 
course  from  the  upper  costa  of  the  scapula,  to  the 
os  hyoides,  and  by  a careful  dissection  in  the  angle 
formed  by  these  two  muscles,  discovered  the 
sheath  of  the  artery,  which  was  immediately  laid 
open  directly  in  front,  and  the  artery  made  bare. 
I passed  under  it,  by  means  of  the  eve-handled 
probe,  an  animal  ligature;  this  upon  tightening 
gave  way,  and  its  place  was  supplied  by  one  of  silk, 
which  was  prepared.  The  artery  being  seem  ed 
by  single  ligature,  I dressed  the  wound  after  my 
common  method  of  securing  incised  wounds.  Du- 
ring the  operation,  which  occupied  altogether 
three  or  four  minutes,  there  were  no  difficulties 
encountered,  either  from  the  jugular  vein  or  ner- 
vus  vagus.  And  when  it  was  over,  I could  not 
avoid  a kind  of  criticism  in  thought,  on  the  ha- 
zards and  difficulties  enumerated  by  Sir  Astley 
Cooper,  hazards  and  difficulties  surely  created  by 
his  fears  and  manner  of  approaching  the  artery. 
Had  this  great  surgeon,  according  to  the  sugges- 
tion of  the  able  Abernethy,  kept  a little  more,  in 
his  cut,  to  the  trachea,  he  would  have  had  no 


APPENDIX. 


483 


occasion  to  alarm  the  profession  by  the  fearful 
deception  he  had  furnished  to  the  world. 

“Subsequent  to  the  operation,  the  patient  was 
free  of  complaint,  except  the  unimportant  sensa- 
tion resulting  from  incision,  until  the  fifth  or  sixth 
day,  when  he  complained  of  pain  and  soreness 
about  the  parotid.  To  this  pain  and  soreness 
succeeded  inflammation,  swelling,  and  finally,  co- 
pious suppuration.  This  was  at  a considerable 
distance,  even  at  its  most  inferior  point  from  the 
wound,  which  continued  to  go  on  well;  he  swal- 
lowed with  facility,  and  breathed  throughout  the 
whole  time  with  the  utmost  ease  and  freedom.  His 
appetite  became  good,  and  he  improved  very 
much  in  flesh  and  strength;  about  the  fifth  week 
he  went  home  in  a vessel,  which  was  at  the 
wharf  from  the  county  in  which  he  lived. 

A day  or  two  previous  to  his  leaving  the  city, 
a very  considerable  haemorrhage  took  place  from 
the  nose;  which,  however,  soon  ceased.  The  lig- 
ature was  not  away,  when  he  left  the  city;  it  was 
cut  close.  But  about  five  days  after  his  arrival 
at  home,  that  is,  about  six  weeks  subsequent  to 
the  operation,  he  was  attacked  by  lock-jaw  (tris- 
mus) of  which  he  died. 

“Mr.  Fitzhugh,  a young  gentleman  of  my  office, 
who  was  present  at  the  operation  and  continued 
to  visit  the  patient,  has  been  so  polite  as  to  in- 
quire into  the  circumstances  of  his  death.  He 
also  reports  that  the  physician  of  the  family, 


484 


APPENDIX. 


examined  after  death  the  parts  concerned  in  the 
operation,  and  found  every  thing  in  the  best  pos- 
sible condition. 

‘‘Had  I been  apprised  of  your  wish  sooner,  I 
would  have  written  to  the  family  physician,  and 
obtained  a detailed  account  of  what  occured. 

Very  respectfully,  yours, 

JOHN  B.  DAYIDGE.” 

October  15,  1823. 

“P.S.  Perhaps  it  may  be  of  moment,  that  I men- 
tion to  you  what  attentions  were  directed  to  the 
tumour  itself,  subsequently  to  the  tying  the  ar- 
tery. The  tumour  was  left  to  itself,  protruded 
down  through  the  opening  in  the  bone.  It  gradu- 
ally fell  into  mortification,  and  sloughed  away 
so  completely,  that  no  vestige  could  be  discovered 
by  the  most  careful  examination,  by  the  finger  in- 
troduced inio  the  antrum;  no  part  was  removed, 
either  by  knife,  scissors,  or  caustic.  I was  solici- 
tous to  ascertain  the  effect  of  tying  the  artery  on 
the  tumour,  and  perceiving  it  to  fall  away  so 
rapidly,  I merely  desired  the  patient  to  pay  re- 
gard to  the  state  of  the  mouth,  and  frequently 
cleanse  it.” 

Since  I have  received  the  proof  of  this  sheet,  I 
have  been  informed  by  my  friend  Dr.  Hall,  that 
lie  has  lately  tied  the  carotid  artery,  in  a case  of 
fungus  ot  the  antrum,  and  that  although  no  ope- 


APPENDIX. 


485 


ration  was  performed  on  the  tumour  itself,  the 
disease  was  removed. 

Believing  the  application  of  this  principle  to 
the  treatment  of  tumours  of  the  antrum  original 
and  important,  I have  considered  it  my  duty  to 
take  some  pains  in  placing  a correct  statement 
of  the  subject  before  the  profession. 


Mr.  Burns,  says  nothing  in  his  work  on  the 
subject  of  operations  for  the  removal  of  portions  of 
the  lower  jaw,  in  cases  where  it  is  affected  with 
medulary  sarcoma.  Indeed,  this  operation  is  one 
of  very  late  date.  Dr.  Mott,  whose  name  I 
have  already  had  occasion  to  mention,  as  one  to 
whom  surgery  is  much  indebted;  was  the  first, 
who  suggested  the  bold  operation  of  removing 
nearly  the  whole  of  the  lower  jaw  in  a case  of  this 
disease,  and  has  now  operated  successfully  in  four 
cases.  It  is  true,  that  we  have  lately  been  infor- 
med that  Graffe,  had  done  something  of  the  same 
kind,  but  the  particulars  are  not  stated.  Dupuy- 
tren,  when  I was  in  Paris,  removed  a considera- 
ble portion  of  the  angle  of  the  jaw,  in  a case 
where  a cancerous  sore  was  situated  over  it;  the 
extent  of  this  operation  was,  however,  trifling  when 
compared  with  those  executed  by  Dr.  Mott.  My 
friend  Dr.  M‘Clellan,  whose  talents  have  already 
procured  for  him  a distinguished  rank  in  his  profes- 


486 


APPENDIX. 


sion,  a few  months  ago,  removed  nearly  the  whole 
jaw  bone  from  a child. 

I transcribe  two  cases  where  this  operation  has 
been  performed.  No.  1,  is  the  first  case  on  which 
Dr.  Mott  operated,  and  No.  2,  is  a notice  of  Dr. 
McClellan’s  case,  published  by  some  person  w ho 
had  witnessed  the  operation,  in  the  Boston  Medi- 
cal  Intelligencer. 

No.  I. 

“Catharine  Bucklew,  the  subject  of  the  follow- 
ing operation,  was  an  interesting  young  woman, 
aged  about  seventeen  years,  of  a healthy  appear- 
ance and  good  constitution. 

“She  says  that  about  two  years  since,  a swelling- 
commenced  behind  the  last  molar  tooth  of  the  low- 
er jaw,  attended  with  acute  pain  about  the  angle 
of  the  jaw,  that  continued  about  three  weeks;  at 
which  time  it  left  her  without  any  evident  resolu- 
tion of  the  inflammation.  At  this  period  there 
was  no  inflammation  of  the  integuments,  nor  could 
any  pus  be  discovered  either  on  the  cheek  or  about 
the  bone  within  the  mouth.  Some  domestic  ap- 
plications wTere  made  to  the  cheek,  but  the  tume- 
faction continued  to  increase,  and  assumed  a 
smooth,  hard,  and  bony  character. 

“About  twrelve  months  after  its  commencement 
she  applied  to  a physician  in  New-Jersey,  who 
advised  her  to  apply  blisters  to  the  cheek,  and  the 
use  of  topical  applications  of  caustic  to  the  tu- 


APPENDIX. 


487 


mour,  together  with  a general  antiphlogistic  con- 
stitutional treatment.  After  having  submitted  to 
this  course  for  two  months  without  experiencing 
any  benefit,  she  came  to  this  city,  and  became  my 
patient. 

“The  first  molar  tooth  came  away  early  in  the 
disease,  and  the  second  soon  followed;  then,  three 
or  four  of  the  other  teeth  of  that  side  of  the  lower 
jaw.  She  states,  that  previously  to  this  disease 
she  never  had  a decayed  tooth. 

“No  fluctuation  was  to  be  felt  at  any  time  in 
the  tumour.  She  had  no  constitutional  symptoms 
as  the  effect  of  this  disease,  nor  any  inordinate 
headache  on  that  side.  The  lymphatic  glands  of 
the  neck  were  however  swollen,  during  the  con- 
tinuance of  the  inflammation  in  the  early  part  of 
the  disease;  but  they  disappeared  as  soon  as  the 
pain  subsided. 

“When  she  came  under  my  care,  the  tumour 
extended  from  the  root  of  the  coronoid  process  to 
the  second  bicuspid  tooth,  elevated  nearly  an  inch 
above  the  level  of  the  teeth,  and  spreading  con- 
siderably wider  than  the  alveolar  process.  Its 
appearance  was  smooth,  and  to  the  touch  some- 
what elastic,  though  firm.  An  incision  on  each 
side  of  the  alveolar  margin,  with  a scalpel,  ena- 
bled me  pretty  readily  to  remove  the  tumour  with 
a gum-lancet  to  the  level  of  the  jaw-bone.  The 
tumour,  on  examination,  contained  many  cartila- 
ginous and  osseus  spiculse,  and  in  the  substance  of 


488 


APPENDIX. 


it  was  imbedded  one  of  the  molar  teeth  in  a per- 
fectly sound  state. 

“About  three  weeks  after  this  operation  a small 
portion  of  the  size  of  a nutmeg,  which  had  gran- 
ulated and  grown  rapidly,  was  taken  off,  and  soon 
after  she  retired  to  the  country,  and  remained  in 
a very  comfortable  state  for  several  months.  The 
tumour  began  now  to  re-appear,  and  continued  to 
increase  gradually  in  every  direction. 

“The  tumour  at  present  (Nov.  10th,  1821,)  has 
the  same  firm  and  slightly  elastic  feel  which  char- 
acterized it  in  the  early  stage,  involving  all  the 
right  side  of  the  inferior  maxillary  bone.  Project- 
ing outwards,  it  produces  great  convexity  of  the 
cheek:  upwards  it  divides  into  two  portions,  the 
outer  and  longest  reaches  up  to  the  os  raalae,  and 
between  the  two  is  a considerable  furrow,  formed 
by  the  teeth  of  the  upper  jawT,  which  occasions 
an  abrasion  and  constant  discharge;  the  latter, 
though  offensive,  does  not  appear  to  be  acrid  or 
irritating;  downwards  it  comes  nearly  in  contact 
with  the  thyroid  cartilage;  inwards  it  extends  be- 
yond the  middle  line  of  the  mouth,  pushing  the 
tongue  and  uvula  very  much  to  the  left  side,  hav- 
ing the  velum  pendulum  palati  of  the  right  side 
attached  to  it  in  its  whole  course.  The  inward 
portion  is  considerably  raised  above  the  level  of  the 
tongue  when  the  mouth  is  opened. 

“The  posterior  extremity  of  the  tumour  has  en- 
croached so  much  upon  the  passage  leading  into 


APPENDIX. 


489 


the  posterior  fauces,  and  the  pressure  of  the  lower 
parts  upon  the  larynx  is  so  considerable,  as  to 
render  deglutition  very  difficult;  and  from  the 
great  difficulty  of  mastication,  she  has  been  com- 
pelled for  some  time  to  subsist  upon  liquid  ali- 
ment. Her  speech  is  considerably  interfered  with 
in  consequence  of  the  displacement  of  the  tongue. 
She  experiences  no  pain  in  any  part  of  the  tu- 
mour. 

“The  gradual  increase  of  the  disease  rendering- 
mastication  and  deglutition  more  difficult  and  dis- 
tressing, she  is  very  desirous  of  knowing  if  an 
operation  could  not  be  performed  which  might 
extend  to  her  some  chance  of  life;  observing,  that 
with  the  constant  growth  of  the  tumour,  such  as 
has  taken  place  for  a few  weeks  past,  she  should 
not  be  able  to  swallow  any  thing  in  a short  time. 
Fully  aware  of  the  dangerous  nature  of  the  novel 
operation  her  case  requires,  she  is  determined  to 
submit  to  it,  and  hazard  the  consequences;  the 
uncertain  result  of  which  I carefully  explained  to 
her,  and  informed  her,  that  she  might  die  during 
the  performance  of  the  operation;  but  that  I be- 
lieved it  to  be  both  practicable  and  proper. 

After  preparing  the  system  for  about  a week 
with  light  diet,  and  the  exhibition  of  several  doses 
of  neutral  salts,  to  obviate  any  great  degree  of 
inflammation,  the  operation  was  commenced  about 
eleven  o’clock  on  the  morning  of  the  17th. 

62 


490 


APPENDIX. 


“As  most  of  the  important  branches  of  the  exter- 
nal carotid  artery  would  be  interfered  with  in  the 
course  of  this  operation,  I believed  it  most  pru- 
dent to  pass  a ligature  around  the  trunk  of  the 
carotids  as  a first  and  preparatory  step.  This 
would  not  only  enable  me  to  go  through  it  with 
more  safety  to  the  patient,  but  appeared  the  most 
important  of  all  means  to  avoid  inflammation. 
Indeed  inflammation  was  much  to  be  dreaded, 
from  the  immense  extent  of  the  external  incision, 
and  the  violence  which  would  necessarily  be  done 
to  the  tongue,  palate  and  pharynx. 

“From  these  considerations,  I felt  it  doubly  im- 
portant to  intercept  the  current  of  blood  through 
the  common  carotid,  and  from  what  I had  ob- 
served to  attend  the  application  of  ligatures  to  the 
large  arteries  of  the  extremities,  in  cases  of  severe 
injuries,  by  preventing  inflammation,  I thought 
great  advantage  would  attend  it  in  this  case,  as  I 
am  satisfied  will  be  fully  shown. 

“An  incision  about  two  inches  and  a half  long, 
was  made  a little  below  the  thyroid  cartilage  on 
the  inner  edge  of  the  sterno-cleido-mastoideus 
muscle,  and  after  exposing  the  carotid,  a single 
ligature  was  passed  under  it  and  tied.  In  this 
situation  it  was  deemed  most  proper  to  tie  the 
carotid,  in  order  to  prevent  the  second  part  of 
the  operation  from  interfering  with  the  first  in- 
cision. Very  little  blood  was  lost,  only  one  small 
cutaneous  branch  at  the  lower  angle  of  the  wound 


APPENDIX* 


491 


required  a ligature;  yet  she  became  pale  and  al- 
most pulseless  during,  and  immediately  after  the 
operation,  notwithstanding  her  position  was  re- 
cumbent. She  submitted  to  the  operation  with 
great  firmness  and  resolution,  but  her  mind  soon 
became  agitated  and  perturbed  to  a great  degree, 
and  it  seemed  altogether  impossible  for  her  to 
regain  her  former  fortitude.  The  operation  was 
suspended,  and  some  cordial  was  administered, 
but  it  failed  to  remove  from  her  mind  the  presen- 
timent that  any  further  proceeding  at  present 
would  be  fatal.  In  this  state  of  remarkable  agi- 
tation I resolved  not  to  proceed,  and  informed 
her  that  with  such  fears  as  she  then  entertained, 
the  result  was  to  be  dreaded.  The  wound  was 
then  dressed,  and  she  was  put  in  bed,  faint  and 
exhausted. 

After  recovering  a little,  I apprised  her  that 
this  was  only  preparatory  to  the  most  important 
part  of  the  operation,  and  that  what  had  been 
done  would  prove  of  little  or  no  benefit  to  the  dis- 
ease, and  urged  her  seriously  to  consider  of  it,  and 
if  possible  make  up  her  mind  to  submit  to  the  per- 
formance of  the  remaining  part,  which  should  by 
no  means  be  deferred  longer  than  the  following 
day. 

One  o’clock,  p.  m. — She  is  still  pale,  and  in  a 
cold  sweat;  pulse  has  not  recovered  itself;  and 
when  asked,  nodded  that  she  felt  some  uneasiness. 


APPENDIX, 


492 

Seven  o’clock,  p.  m. — Much  more  collected; 
pulse  natural;  no  uneasiness  whatever,  except 
some  obtuse  pain  about  the  wound  in  breathing, 
and  in  swallowing  saliva;  no  increase  of  heat;  left 
a student  to  watch  with  her  through  the  night, 
and  again  took  leave,  earnestly  recommending  to 
her  private  consideration  ihe  expediency  of  sub- 
mitting to  the  remainder  of  the  operation. 

18th. — Seven  o’clock,  a.  m. — Found  her  this 
morning  in  a very  composed  state  of  mind;  having 
slept  well,  and  free  from  fever.  Upon  putting 
the  question,  would  she  submit  to  the  remainder 
of  the  operation?  she  nodded  assent  with  much 
apparent  decision,  and  said  she  was  determined 
to  undergo  it. 

“At  ten  o'clock,  finding  my  patient  cheerful 
and  resolute,  she  was  again  placed  upon  the  table, 
and,  in  the  presence  of  William  Anderson,  sur- 
geon, Dr.  Hosack,  and  a number  of  other  gentle- 
men, the  operation  was  continued.  Feeling  for 
the  condyloid  process,  an  incision  was  commenced 
upon  it,  opposite  the  lobe  of  the  ear,  carried  down- 
wards over  the  angle  of  the  jaw  in  a semicircular 
direction  along  the  lower  part  of  the  tumour,  as  it 
rested  upon  the  thyroid  cartilage,  and  terminated 
it  about  half  an  inch  beyond  the  angle  of  the 
mouth,  on  the  chin.  The  termination  of  this  in- 
cision upon  the  chin,  was  just  above  the  attach- 
ment of  the  under  lip  to  the  bone,  and  the  mouth 
was  thereby  laid  open.  1 now  extracted  the  se- 


APPENDIX. 


49S 


cond  incisor  tooth  of  that  side,  as  it  was  in  a sound 
part  of  the  bone,  and  after  separating  the  soft  parts 
from  the  side  of  the  chin,  and  laying  bare  the 
bone,  I introduced  a narrow  saw,  about  three  in- 
ches long,  similar  to  a key  hole  saw,  from  within 
the  mouth,  through  the  wound,  and  sawed  through 
the  jaw  bone  from  above  downwards.  The  lower 
part  of  the  tumour  was  then  laid  bare,  by  cutting 
through  the  mylo-hyoid  muscle,  and  the  flap  of 
the  cheek  carefully  separated  and  turned  up  over 
the  eye.  This  exposed  fully  to  view  the  whole 
extent  of  the  tumour  as  it  rose  upwards  to  the  os 
malse.  After  the  integuments  were  carefully  dis- 
sected from  the  parotid  gland,  the  masseter  mus- 
cle was  detached  from  its  insertion, until  it  came  to 
the  edge  of  this  gland,  then  separating  a thin 
plane  of  the  fibres  of  this  muscle,  I now  readily 
raised  the  parotid,  without  wounding  it  at  this 
part.  The  maxilla  inferior  was  now  laid  bare 
just  below  its  division  into  two  processes,  and  it 
appeared  sound.  To  facilitate  the  sawing  of  the 
bones,  it  was  necessary  to  make  a second  incision, 
about  an  inch  long,  close  to  the  lobe  of  the  ear, 
and  terminating  at  the  edge  of  the  mastoid  mus- 
cle; then,  with  a fine  saw,  made  for  the  purpose, 
smaller  and  more  convex  than  Hey?s,  I began  to 
saw  through  the  bone,  obliquely  downwards  and 
backwards,  and  finished  with  one  less  convex. 
The  latter  part  of  the  sawing  was  done  with  great 
caution,  to  avoid  excruciating  pain  from  the  lacer- 


494 


APPENDIX. 


ation  of  the  inferior  maxiliary  nerve.  When  the 
bone  was  sawed  through,  the  two  processes  were 
observed  to  be  split  asunder,  and  the  coronoid 
to  be  drawn  up  by  the  action  of  the  temporal 
muscle. 

“An  elevator  was  now  introduced  where  the 
bone  was  divided  at  the  chin,  by  which  the  dis- 
eased portion  was  raised,  when,  with  a scalpel 
passed  into  the  mouth,  the  tumour  was  separated 
from  the  side  of  the  tongue,  as  far  back  as  the 
posterior  fauces,  from  the  velum  pendulum  palati 
and  pterygoid  processes.  This  loosened  it  very 
much,  so  that  it  could  be  turned  upon  the  side  of 
the  neck.  It  was  then  separated  from  the  parts 
below  the  base  of  the  jaw,  and  also  from  the 
pharynx,  and  detached  at  the  posterior  angle, 
carefully  avoiding  the  trunk  of  the  internal  caro- 
tid and  deep-seated  jugular  vein,  both  of  which 
were  exposed. 

“The  diseased  mass,  being  now  separated  above 
and  below,  was  turned  up,  the  pterygoid  muscles 
detached,  and  the  third  branch  of  the  fifth  pair 
of  nerves  divided  from  below,  a little  above  the 
foramen  at  which  it  enters  the  bone.  By  this 
manner  of  proceeding,  with  a constant  reference 
to  this  nerve,  I apprehend  my  patient  was  sav- 
ed from  much  acute  pain,  and  the  nerve  more 
safely  divided,  than  at  an  earlier  stage  of  the 
operation. 


APPENDIX. 


495 


“ At  several  periods  of  this  operation,  the  cur- 
ved spatulas,  used  in  my  operation,  upon  the  ar- 
teria  inorninata,  were  found  very  useful,  particu- 
larly in  elevating  the  parotid  gland,  and  keeping 
the  tongue  steady,  whilst  the  tumour  was  separa- 
ted from  it. 

“Very  little  blood  was  lost  during  this  opera- 
tion. Two  arteries  only  of  any  size  were  divided, 
the  facial  and  lingual;  and  these  only  required  the 
ligatures  at  the  branch  extremities;  but  each  end 
was  tied  for  safety.  Another  small  artery  behind, 
and  a little  underneath  the  posterior  angle  of  the 
jaw,  yielded  some  blood  and  was  tied. 

“The  flap  of  the  cheek  was  now  brought  down, 
after  waiting  a few  minutes  to  observe  if  any  hae- 
morrhage  should  come  on,  and  secured  in  close  ap- 
position by  three  sutures,  and  adhesive  straps. 
Lint,  a compress,  and  the  double-headed  roller, 
completed  the  dressing.  She  was  made  as  com- 
fortable as  possible  upon  the  table,  and  directed  to 
remain  a few  hours  to  recruit,  and  to  be  more  con- 
venient in  case  any  haemorrhage  should  make  it 
necessary  to  remove  the  dressings. 

“At  eight  o’clock  in  the  evening,  I found  her 
removed  to  a bed,  and  in  a comfortable  situation. 
Some  reaction  of  the  circulation  had  taken  place, 
but  there  had  been  no  haemorrhage.  The  pain 
from  the  operation,  she  said,  was  less  than  she  ex- 
pected. For  the  first  time,  since  the  operation, 
she  sipped  three  tea-spoons  full  of  cold  water, 


496 


APPENDIX. 


and  gave  evidence,  by  a nod,  that  she  could  swal- 
low. Directed  one  hundred  drops  of  tinct.  opii 
to  be  given,  if  any  twitching,  more  pain,  or  rest- 
lessness should  supervene. 

“19th. — Seven  o’clock,  a.  m. — Found  her  quite 
free  from  fever  and  irritation,  and,  in  everv  res- 
pect comfortable.  Swallows  cold  water  by  the 
tea-spoon  full  with  hut  little  inconvenience.  Did 
not  take  the  tinct.  opii  last  night.  Slept  several 
hours  during  the  night. 

“Twelve  o’clock,  at  noon — Is  comfortable;  skin 
moist;  pulse  less  frequent,  and  soft;  directed  an 
enema  to  be  administered  of  soft-soap  and  water; 
has  a little  more  difficulty  in  swallowing,  but  none 
in  breathing. 

Nine  o’clock,  p.  m. — As  well  as  in  the  morning. 
Enema  operated  three  times,  and  relieved  her. 
Pulse  frequent,  but  not  tense.  She  has  taken 
about  two  ounces  of  cold  water  by  the  tea-spoon 
full  since  day  light. 

20th. — Seven  o’clock,  a.  m. — Had  a very  com- 
fortable night.  This  morning,  instead  of  nodding 
she  answers  “yes”  and  “no”  to  the  several  ques- 
tions, in  an  audible  whisper. 

Nine  o’clock,  p.  m. — Much  as  in  the  morning. 

21st. — Nine  o’clock,  a.  m. — As  comfortable  as 
yesterday  morning. 

Nine  o’clock,  p.  m. — No  material  alteration. 

22d. — Nine  o’clock,  a.  m. — Directed  an  enema 
to  be  administered  as  before.  Allowed  her  to 


APPFNDIX. 


497 


take,  in  addition  to  her  cold  water  and  teas,  some 
thin  chicken  soup;  is  in  every  respect  doing  well. 

“Nine  o’clock,  p.  m. — Tumefaction  of  the  lips 
and  cheek  very  trifling,  not  etc  ugh  to  effect  the 
least  change  in  the  eye-lids  of  the  right  eye. 

“23d. — Is  in  every  respect  comfortable. 

“24th. — Eleven  o’clock,  a.  m. — Makes  no  com- 
plaint; dressed  the  wounds;  union  by  adhesion 
has  taken  place  in  the  whole  extent,  excepting 
about  the  ligatures  and  sutures.  Suppuration 
having  come  on  about  two  of  the  sutures,  they 
were  removed.  Pulse  about  one  hundred  and 
twenty.  Renewed  the  adhesive  straps  with  lint 
interposed  between  them  and  the  wound,  and  the 
double-headed  roller. 

“25th. — Every  way  comfortable.  Pulse  one 
hundred  and  twenty. 

“26th. — Says  she  has  no  complaint  to  make. 
Pulse  eighty.  Directed  her  to  take  a small  dose 
of  sulphate  of  magnesia. 

27th. — Speaks  audibly,  and  says  she  is  very 
well;  pulse  about  eighty-four. 

28th.-— As  well  as  before;  dressed  the  wounds; 
removed  the  two  sutures  at  the  upper  part  near 
the  ear;  wounds  appear  healed  at  every  part,  ex- 
cept where  the  ligatures  remain  upon  the  arteries. 
Pulse  eighty. 

29th. — Feels  very  well;  speaks  distinctly:  takes 
freely  of  soup  and  other  thin  food:  pulse  one  hun- 
dred. 


63 


498 


APPENDIX. 


‘•December  3d. — Ligature  from  the  carotid  came 
away  and  the  other  three  ligatures  from  the  up- 
per wound.  A small  collection  of  matter  was 
evacuated  from  under  the  integuments  in  the  low- 
er wound,  which  was  produced  by  the  irritation 
of  the  ligature. 

“4th. — Speaks  and  swallow's  very  well;  wounds 
just  healed.  Has  used  for  some  days  a wash  of 
spirits  and  water  to  the  mouth  with  a view  to 
correct  some  foetor  of  the  saliva,  and  cleanse  the 
mouth. 

“6th. — Found  her  dressed  and  sitting  in  an  ad- 
joining room,  reading  by  the  fire;  looks  and  says 
she  is  very  well.  The  bandages  being  all  left  off, 
the  only  deformity  apparent  is  a little  more  tume- 
faction of  the  right  cheek  than  the  left;  wounds 
just  well;  can  move  very  readily  the  sound  half 
of  the  under  jaw.  Permitted  her  to  chew  some 
animal  food. 

“10th. — Wounds  all  healed — makes  no  com- 
plaint. 

“March,  1822. — To-day  having  visited  her,  I 
found  scarcely  any  perceptible  deformity.  The 
right  cheek  appeared,  upon  close  examination,  to 
be  a little  more  depressed  than  the  left.  I felt 
from  within  the  mouth  some  osseous  deposit  to 
have  commenced  at  the  two  situations  at  which 
the  bone  was  divided.  Her  health  in  every  res- 
pect is  perfectly  good,  and  she  enjoys  the  free  use 
of  the  lett  side  of  the  lower  jaw. 


APPENDIX. 


499 


“November  5th. — I have  repeatedly  heard  of 
and  seen  the  patient  during  the  past  season,  and 
sfie  continues  to  enjoy  uninterrupted  health.” 

No.  II. 

“A.  B.  aged  four  years,  had  a severe  fall  upon 
her  chin,  which  loosened  the  lower  incisors;  they 
became  black  The  whole  substance  of  the  jaw 
in  front  began  to  swell  soon  after,  upward  and 
backward,  till  the  swelling  filled  the  mouth,  and 
downward  and  forward,  so  as  to  produce  most 
hideous  deformity.  The  skin  of  the  chin  and 
lower  lip  was  greatly  attenuated,  and  protruded 
downward  by  the  tumour,  so  as  to  overlap  the  os- 
hyoides  and  thyroid  cartilages.  The  vessels  were 
considerably  enlarged;  the  arteries  beat  actively 
on  almost  every  part  of  the  surface.  The  part  of 
the  tumour  which  projected  out  of  the  mouth,  and 
was  uncovered  by  the  lip,  presented  precisely  the 
appearance  of  an  enlarged  tongue;  the  parents 
declared  that  every  physician  who  had  seen  it 
before,  had  mistaken  it  for  the  tongue,  which  was 
not  easily  discovered,  even  by  the  closest  inspec- 
tion; for  it  was  pushed  backward  by  the  tumour 
into  the  upper  part  of  the  pharynx.  The  lympha- 
tic glands  did  not  appear  affected.  The  child’s 
genera!  health  was  declining  fast. 

“An  incision  was  made  from  the  left  com- 
missure of  the  lips  downward,  and  backward 


500 


APPENDIX. 


over  the  anterior  edge  of  the  mastoid  muscle,  so 
as  to  command  the  carotid  in  case  it  should  be- 
come necessary  to  secure  it.  The  anterior  edge 
of  this  incision  was  then  extended  forward  by  a 
bold  and  rapid  dissection,  till  the  whole  surface  of 
the  tumour  was  uncovered  round  to  the  opposite 
side.  Though  numerous  arterial  twigs  bled,  he 
did  not  stop  to  meddle  with  them,  but  proceeded 
at  once  to  secure  the  facial  artery  on  each  side, 
just  as  it  emerged  from  the  submaxillary  gland 
beneath  the  jaw.  As  this  supplied  nearly  all 
the  divided  twigs,  the  haemorrhage  immediately 
ceased.  The  surface  of  the  sound  bone  being 
next  exposed  behind  the  tumour,  the  metacarpal 
saw  was  applied  on  each  side,  so  as  to  divide  the 
bone  just  in  front  of  its  angles.  By  pressure  in 
front,  the  whole  tumour  was  turned  outward  from 
the  mouth  with  a crash,  and  carefully  dissected 
from  the  under  surface  of  the  tongue,  and  sub- 
maxillary glands  and  muscles  on  each  side.  A 
part  of  the  sublingual  glands,  and  a considerable 
portion  of  the  left  submaxillary  appearing  to  be 
tumefied  and  somewhat  discoloured,  he  removed 
them  by  the  scalpel. 

“Only  three  more  small  twigs,  probably  branch- 
es of  the  lingual  artery,  required  to  be  secured. 
Not  more  than  six  or  eight  ounces  of  blood  were 
lost:  the  patient  did  not  faint.  The  huge  flap,  or 
rather  pouch  of  skin  was  re-applied,  and  the  edges 
of  the  first,  and  only  incision,  were  retained  in 


APPENDIX. 


501 


apposition  by  three  sutures  and  some  strips.  The 
large  cavity  left  beneath  the  tongue  was  partly 
filled  by  lint,  bent  into  the  shape  of  the  lost  circle 
of  hone,  upon  which  the  pendulous  integuments 
were  afterwards  lightly  braced  by  a bandage. 
The  wound  healed  in  less  than  three  weeks,  inter- 
nally and  externally.  The  divided  extremities  of 
bone  shot  out  a luxuriant  crop  of  granulations, 
which  have  since  become  ossified,  so  as  to  extend 
the  angles  of  the  jaw  nearly  an  inch  on  each  side 
towards  the  point  formerly  occupied  by  the  chin. 
The  girl  speaks  and  eats  nearly  as  well  as  ever, 
and  goes  to  school  every  day  in  good  health  and 
spirits.’’ 


INDEX 


Page. 

ABiEffETinr,  Mr.  his  classification  of  tumours,  how  far  usetul,  . 52 

his  description  of  medullary  sarcoma,  . 246 

his  case  where  tic  douloureux  recurred  after 
removal  of  half  an  inch  of  affected  nerve,  313 
has  proved  that  some  encysted  tumours  require 
to  have  their  cyst  destroyed  to  prevent  a return 
of  the  disease,  ....  366 

tied  the  carotid  artery,  but  the  patient  died,  192 
Abscess  over  (esophagus  to  be  opened  early,  . . . 104 

of  thyroid  gland,  effects  produced  by,  . . 215 

in  tonsil,  to  be  punctured  before  pointing,  . . . 280 

case  where  in  puncturing,  large  artery  was  opened,  281 
where  large,  when  it  bursts,  patient  sometimes  suffo- 
cated, ......  282 

sometimes  bursts  on  fore  part  of  velum,  and  sore  re- 
sembles venereal  ulcer,  ....  280 

how  to  be  opened,  ....  283 

Albucasis  relates  a case,  where  in  removing  a diseased  thyroid  gland, 

a large  artery  of  the  neck  was  cut,  ....  253 

Anastomosing  twigs  of  arteries  support  the  member  after  obliteration 

of  the  large  vessel,  .....  163 

Anatomy,  relative,  at  the  angle  of  the  jaw,  . . . 259 

Anel,  his  operation  for  the  cure  of  aneurism,  . . . 161 

Aneurism,  anastomosing,  arterial,  remarks  on,  . . . 340 

case  of,  on  temple,  . 342 

may  be  cured  by  tying  the  great  artery  lead- 
ing to  the  morbid  parts,  . . 464 

venous  case  of,  * . . 331 


504 


INDEX, 


Aneurism,  inorainata,  ease  of,  was  mistaken  for  subclavian  aneurism,  02 
Mr.  F’attison’s  case  of.  . . . 427 

external,  maj  be  cured  occasionally  by  general  compression,  463 
dissection  of,  .....  69 

carotid  parts  concerned  in  operation  for,  . . 194 

effects  of  operation  on  the  limb  anil  tumour,  . 172 

operation  for,  generally  among  the  ancients  failed,  . 159 

sometimes  fails  from  bursting  of  an  internal 
aneurism,  . . . . 167 

treatment  previous  and  subsequent  to  the  operation  for,  200 
Arteria  transversalis  faciei,  description  and  anomally  of,  . 316 

Arteriotomy,  how  to  be  performed,  ....  393 

Artery,  adhesion  of  its  sides,  may  be  procured  by  merely  retaining 

them  in  contact,  ......  143 

anatomical  description  of  its  coats,  note,  . . 139 

change  produced  on,  by  ligature,  . . . 147 

detachment  of,  from  connexions,  frequent  cause  of  second- 
ary liEemorrhage,  .....  156 

how  to  be  treated  in  operation  for  cure  of  aneurism,  . 174 

sheath  of,  tied  by  mistake  lor  vessel,  . . 127 


Br.ix,  Mr.  J.  his  advice  not  to  remove  part  ofan  anastomosing  aneurism 

without  removing  the  whole,  not  always  to  be  adhered  to,  350 
remarks  on  his  assertion,  that  he  has  removed  the  parotid 


gland,  .......  294 

his  description  of  the  point  where  the  common  carotid  di- 
vides, erroneous,  ....  124 

saw  a patient  with  carotid  aneurism,  . . 193 

Bell,  Mr.  C.  his  experiment,  which  shows  that  adhesion  of  the  sides 
of  an  artery  may  be  obtained  by  placing  a ligature 
loosely  around  it,  ....  144 

his  remarks  on  gangrene  after  the  operation  for  aneurism,  184 
Bichat’s  description  of  the  effects  produced  on  the  coats  of  an  artery 

by  ligature,  .....  140 

Bleeding,  arising  from  slipping  of  ligature,  causes  of,  . . 155 

Blizzard,  Mr.  tied  arteries  of  enlarged  thyroid  gland,  after  which  the 

tumour  diminished,  but  patient  died  from  hospital  gangrene,  229 
Bronchocele,  not  the  cause  of  cretinism,  . . . 219 

dissection,  of  a case  of,  ....  222 

remarks  on,  .....  225 

treatment  of,  . . . . . 230 

Bronchotomy,  seldom  or  never  required  in  asphyxia,  . . 406 

performed  either  to  admit  air  into  the  lungs,  or  to 
extract  foreign  bodies  from  the  trachea,  . . 410 


INDEX, 


505 


Brotva,  Dr.  his  case  of  tumour  between  the  masseter  and  buccinator 

muscles,  cured  by  a seton  below  the  jaw,  , 301 

Calculi  in  the  sublingual  gland,  .....  273 

in  the  tonsil,  ......  286 

mode  of  extracting  them,  . . . 290 

Carcinoma,  general  description  of,  . . . 233 

of  thyroid  gland,  case  of,  and  dissection,  . . 233 

and  fungus  htematodes,  are  they  ever  cn-existent  in  dif- 
ferent parts  of  the  same  body,  or  of  the  same  organ?  244 
Carotid  aneurism,  description  of  the  operation  for,  . . 201 

artery,  an  instance  in  which  all  the  primary  branches  of  the 

external  carotid  arose  at  one  point,  . . 125 

an  instance  in  which  the  common  carotid  sent  off 
branches  up  to  the  root  of  the  styloid  process,  . 125 

case  in  which  it  was  buried  in  the  centre  of  an  enlarged 


thyroid  gland,  .....  249 

common,  an  instance  in  which  it  divided  into  the  inter- 
nal and  external  vessels,  three  inches  below  the 
angle  of  the  jaw,  .....  125 

external  connexions  with  the  parotid  gland,  . 290 

how  to  be  found  in  the  living  body,  . . .99 

most  liable  to  disease  at  its  division,  . . 191 

not  endangered  in  performing  the  operation  of  cesopha- 
gotomy,  .....  10 

place  of  its  division  in  childhood,  . . . 401 

position  of,  in  lower  region  of  the  neck,  . 103 

relations  of  the,  .....  110 

reasons  why  a knowledge  of  the  anomalies  of  that  vessel 
are  valuable  to  the  operator,  . . . 200 

Changes  produced  in  the  relations  of  the  parts  below  the  jaw,  by  bend- 
ing back  the  head,  ......  266 

Coagulum,  probable  reason  why  formed,  and  under  what  circum- 
stances formed  in  an  artery  which  has  been  tied,  . 146 

Coleman,  Mr.  advocate  for  laryngotomy,  ....  414 

Compression,  general,  usual  mode  employed  by  the  ancients  for  the 

cure  of  aneurism,  . . . 130 

in  aneurism,  how  to  be  employed,  . . 133 

often  fails  from  being  improperly  applied,  132 

what  are  those  cases  when  advisable,  aud  what 
are  those  where  injurious?  . . 131 

Conglobate  glands  at  the  angle  of  the  jaw,  case  of,  where  they  were 

extirpated,  .....  297 

tumour  formed  by,  in  the  centre  of  the  parotid,  305 


64 


506 


INDEX. 


Conglobate  glands,  between  hyoid  bone  and  thyroid  cartilage,  connec- 
tions of,  . . . . . 116 

tumour  formed  by  these  glands,  case  of,  and  dissec- 
tion of  person,  ....  117,118 

critical  remarks  on  this  case,  . . . 121 

over  the  oesophagus  swell,  forming  tumours  which 
may  be  extirpated,  ....  103 

Contents  of  space  between  sterno-rnastoid  and  trapezius  muscles  im- 
mediately above  the  clavicle,  ....  76 

Cooper,  Mr.  Astley,  his  case  of  aortic  aneurism,  where  the  disease 

was  supposed  to  be  seated  in  the  carotid  artery,  71 
his  case  of  carotid  aneurism,  . . . 204 

first  case  in  which  he  operated  on  carotid  aneu- 
rism, patient  died,  . . . 193 

remarks,  that  aortic  aneurism  may  be  mistaken 
for  subclavian  aneurism,  • . .60 

Coronary'  arteries  of  the  lip,  origin  and  course  of,  . . 354 

Cricoid  cartilage,  situation  of,  .....  96 

Cruickshanks,  Mr.  saw  an  enlarged  lymphatic  gland  mistaken  for 

diseased  parotid  gland,  .....  293 

Davidoe,  Dr.  his  case  of  tumour  in  antrum,  . . . 481 

Desault  & Deschamps,  their  opinion,  that  in  aneurism,  a ligature  ap- 
plied to  the  artery,  further  from  the  heart  than  the  tu- 
mour, would  have  proved  efficacious,  erroneous,  . 186 

extirpated  the  right  lobe  of  the  thyroid  gland,  . 252 

shewed  that  a cur  ved  tube  might  be  easily  introduced,  by  the 
right  nostril,  into  the  larynx,  . . . 407 

Diseased  thyroid  gland,  relations  of,  ....  253 

Dissection  of  a man  who  died  sometime  after  the  subclavian  artery 

had  been  tied,  .....  93 

of  a tumour  formed  by  a concatenated  gland,  where  the 
common  carotid,  jugular  vein,  and  nervus  vagus  were 
buried  in  its  substance,  ....  115 

Distance  between  the  chin  and  chest  in  the  adult,  when  the  base  of 
the  scull  is  parallel  to  the  horizon,  and  general  relation  of 
parts  in  this  region,  . . . . .95 

between  the  chin  and  chest  in  the  adult,  when  the  occiput  is 
turned  back,  and  the  alterations  in  the  relations  of  parts 
by  this  change  of  position,  ....  97 

between  the  chin  and  chest  in  the  young  child,  and  the  rela- 
tion of  the  parts  in  this  region,  when  the  base  of  the  scull 
is  parallel  to  the  horizon,  ....  399 


INDEX. 


50? 


Distance  between  the  chin  and  chest  in  the  young  child,  and  the  effect 

produced  on  those  relations  bv  turning  back  the  head,  400 
Dropsy  of  thyroid  gland  sometimes  cured  by  solution  of  muriate  of 

ammonia,  .......  218 


Edentulous  subject,  remarks  on  the  conformation  of  the  neck  of,  423 
Ehrlich,  his  case  of  ranula,  .....  274 

Emphysema,  spontaneous,  authors  who  have  written  on  it,  . 83 

case  where  it  happened,  . . 84 

causes  of,  . . .85 

Epiphora,  not  constant,  when  the  nasal  duct  is  obstructed,  . 365 


Facial  artery,  relations  ot,  .....  265 

course  of,  .....  353 

tumours  ought  to  he  removed  with  capsula  entire,  . 325 

case  of,  .....  328 

Fascia,  cervical,  description  of  the  .....  33 

consequences  resulting-  from  its  destruction,  . 36 

Febrile  state,  dependent  on  peculiarity  of  constitution  renders  opera- 
tion abortive,  . . . . . .179 

Femoral  artery,  subject  in  which  about  two  inches  of  that  vessel 

were  obliterated,  ......  142 

Fistula  lachrymalis,  remarks  on,  .....  363 

Freytag,  extirpated  the  thyroid  gland,  ....  252 

Frsenum  lingiwe,in  snipping,  how  to  avoid  injuring  the  arteria  ranina,  264 
Fungus  fromthesore,  after  removal  of  the  tonsil,  how  to  be  destroyed,  285 
in  antrum,  ease  of,  .....  384 

liEematodes  behind  the  jaw,  case  of,  . . . 307 

contrasted  with  carcinoma,  . . . 240 

general  description  of,  • , . 237 

propagated  otherwise  than  by  absorption,  . 381 


Gangkene,  produced  by  the  use  of  stimuli,  after  operation  for  aneu- 
rism— how?  . . . . . 178 

seldom  dependent  on  insufficient  circulation,  but  on  over 
excitement,  . . . . . .181 

Gariot,  destroyed  fungus  in  antrum  by  actual  cautery,  . 383 

his  assertion  that  glandular  substance  is  incapable  of  suppu- 
rating, ......*  273 

Gooch,  his  cases  of  extirpation  of  the  thyroid  gland,  . . 254 

Glandules  Concatenate,  case  of  a female,  in  whom  enlargement  of 
one  of  these  glands  was  mistaken  for  ca- 
rotid aneurism,  . . . Ill 


508 


INDEX, 


Glanuulx  Concatense,  situation  of  the,  . . . .lit 

symptoms  induced  by  their  enlargement  . 114 

tumour  formed  bv,  how  to  discover  its  con- 
nexions on  the  living  subject,  . . 114 

tumour  formed  by,  how  to  be  extirpated,  . 116 

Glands,  conglobate,  below  the  jaw,  tumours  formed  by,  relations  of,  267 

only  under  certain  circumstances 
that  they  can  be  extirpated,  270 
connected  with  the  parotid  gland,  . . 295 

Gland  conglobate  lodged  in  the  parotid,  tumour  formed  by  it  mistaken 

for  diseased  parotid,  . . , SOG 

submaxillarv, relations  of,  . 265 

thyroid,  dissimilar  effects  produced  by  enlargement  of,  . 214 

its  different  parts  when  swelled,  but  not  from  specific 
disease;  tumour  if  loo  large  to  admit  of  extirpation, 
may  be  reduced  by  tying  its  nutrient  arteries,  . 228 
Gullet,  foreign  substances  impacted  in,  ...  105 

Hall  Hi,  met  with  the  lower  thyroid  artery  arising  from  the  carotid,  418 
twice  saw  the  black  variety  of  fungus  hxraatodes,  . 385 

Harrold,  Mr.  lost  a patient  from  effusion  of  blood  into  the  trachea,  420 

Heberden,  Dr.  bis  cases  of  pulsating  tumours  which  disappeared 
without  suppurating  or  bursting,  were  probably  enlarged 
glands  over  the  common  carotid  artery,  . . 113 

Hemorrhage,  secondary, arises  from  including  parts  around  the  artery,  153 
causes  of,  . . . . 148 

Home,  Sir,  Everard,  has  shewn  that  the  tongue  may  be  extirpated 

by  ligature,  ....  262 

Humeral  artery,  obliterated  without  any  obvious  cause,  . . 148 

Hunter,  Mr.  John,  the  first  scientific  improver  of  the  operation  for 

the  cure  of  aneurism,  . . . 164 

causes  of  failure  in  his  first  operation  for  aneurism,  165 
Hyoid  bone,  situation  of,  ...  . 96 

Internal  maxillary  artery,  case  of  anastomosing  aneurism  of,  . 464 

successfully  treated  by  the  application  ol  a 
ligature  to  the  common  carotid,  . 475 

Jones,  Dr.  his  description  of  the  effects  produced  by  the  application  of 

a ligature  on  an  artery',  . . . . IS 

opinion  that  early  exertion  may'  rupture  a newly  adhered 
artery,  considered,  ...  . 158 

supposition  that  division  of  the  two  internal  coats  of  an 
artery  is  essentially  necessary  to  adhesion,  erroneous,  141 


INDEX, 


509 


Jugular  vein,  situation  of,  ..... 

abscess,  burst  into,  ■ . . 

dilatation  of,  case  where  it  formed  a tumour  just  below 
the  angle  of  the  jaw,  .... 

Ltbtalts  superficialis.  arteria,  origin  of,  ... 

Lachrymal  duct,  mode  of  examining  the,  .... 
stricture  of,  how  to  be  treated, 

Lachrymal  gland,  diseased,  case  of,  .... 

dissection  of,  . . . . 388. 

sac,  situation  of,  ..... 

Ltennee  describes  a peculiar  variety  of  fungus  hEematodes,  note, 
Laryngotomv,  objection  to  its  performance, 

Li  gature,  improperly  applied,  how  productive  of  secondary  litemorr- 
hage,  ...... 

instantaneous  effects  produced  by  its  application  on  the  aneu- 
rismal  arteries,  ...... 

never  requires  to  be  stitched  to  the  vessel, 

of  reserve,  highly  injurious,  .... 

Lingual  artery,  relations  of,  .... 

nerve,  description  of  its  relations, 

Lip,  cancerous,  disease  reproduced  after  operation  in  gland  below  the 
jaw,  ....... 

wounds  of,  often  improperly  dressed,  .... 

case  where,  from  improper  treatment,  it  was  burst 
asunder,  after  it  had  been  dressed, 

Mattel  art  artery,  internal  origin  of,  . 

M‘ Donald,  .Virs.  case  of  diseased  glands  below  the  jaw. 

Medullary  sarcoma,  description  of,  in  thyroid  glaud, 

is  it  the  same  disease  as  fungus  htematodes? 

Mott.  Dr.  his  case,  where  the  arteria  innominata  was  included  iu  a 
ligature,  ...... 

case  of  osteo  sarcoma,  in  which  a portion  of  the  lower  jaw 
was  successfully  removed, 

Neck,  division  of,  into  regions — middle  region  of,  howto  be  discovered, 
Needles  sewing,  finely  polished,  useful  in  wounds  of  the  lip,  . 

Nerves,  experiments  on  their  re-union,  by  Dr.  Haughton,  note, 
Nervus  descendens  noni,  description  of  the, 

Occipital  artery,  description  of, 

CEsophagotomy,  anomalous  vessel  endangered  in  operation, 

relative  anatomy  of  the  parts  concerned  in  this  ope- 
ration, ...... 

Optic  nerves,  dissection  of,  which  proved  that  they  did  not  decussate, 


100 

103 

303 

353 

357 

361 

386 

„89 

356 

385 

414 

150 

172 

156 

160 

261 

261 

271 

354 

355 

392 

269 

247 

245 

433 

486 

101 

355 

312 

100 

260 

109 

106 

3S1 


510 


INDEX 


Parotid  duct,  course  and  connexions  of,  ....  313 

sunk  into  soft  tumours  protruding  from  between  the 
masseter  and  buccinator  muscles,  . . 320 

gland,  lobe  of,  forming  an  encysted  tumour,  . . 302 

proof  that  it  cannot  be  extirpated,  . . 292 

situation  of,  . . 291 

Pharynx,  its  mode  of  junction  with  the  oesophagus, 

Platysma  Myoides,  description  of,  . • . . . ^2 

use  of  this  muscle  considered,  . . 33 

Portal  remarks,  that  a connection  exists  between  the  cellular  mem- 

brane  of  the  neck,  and  texture  of  the  lungs,  . . S3 

Portio  dura,  description  of,  ....  308 

Prosser,  his  description  of  bronchocele  unsatisfactory,  . . 220 

Pulsation  of  a tumour  resembling  true,  manner  in  which  apparent  may 

be  distinguished  from  real  pulsation,  . , . 112 

Pnrmanus,  his  case  of  tumour  at  the  inner  ear.thus  of  the  eye,  . 365 

Physick,  Ur.  his  mode  of  extiipating  diseased  tonsils,  . . 400 

Kanula,  description  of,  . . . . . . 274 

treatment  of,  . . . . . .276 


Salivary  glands,  inflammation  of,  .... 

Scarpa’s  description  of  the  state  in  which  he  found  the  femoral  artery 
shortly'  after  amputation,  . 

mode  of  operation  for  aneurism, 
success  greater  than  that  of  Mr.  Hunter,  . 

Scott,  Mrs.  her  case  of  diseased  eye,  .... 

dissection  of  the  body,  ..... 

Sinuses  in  vicinity  of  artery,  causes  of  secondary  hsemorrhage. 

Spinal  accessory  nerve,  position  ot,  . . .* 

Sterno-mastoid  and  omo-hyoid  muscles,  point  where  they  decussate 
each  other,  how  to  be  discovered  in  the  living  subject, 
Sterno-mastoid  and  omo-hyoid  muscles,  point  where  they  intersect 
each  other  in  the  child,  ..... 

Sternum  and  thyroid  gland,  relative  distance  between  those  parts  at 
different  ages,  ...... 

Socio  parotidis,  description  of, 

Stimuli  applied  to  limb,  subsequent  to  the  operation  of  aneurism,  in- 
jurious, ....... 

general,  effects  resulting  from  their  use  after  operation  for 
aneurism,  case  of,  .... 

Subclavian  artery,  case  where  an  attempt  was  made  to  tie  it  previous 
to  its  passage  between  the  scaleni  muscles, 
course  and  connexions  of  the, 


145 

166 

16S 

371 

376 

152 

2C0 

99 

402 

405 

317 

173 

174 


86 

58 


INDEX. 


511 


Subclavian  artery,  successful  operation  of  Mr.  Ramsden,  . . 8“ 

Superior  laryngeal  nerve,  course  and  connexion  with  artery  described,  110 
Sympathetic  nerve,  situation  of  the,  ....  100 

Temporal  artery,  course  of  the,  .....  393 

Thymus  gland,  situation  and  connexions  of  the,  . . 39 

scrophulous  enlargement  ot — fatal  consequences  re- 
sulting from  its  pressure  on  the  subclavian  vein  and 


trachea,  ......  39 

removal  of,  proposed,  ....  41 

Thyroid  arteries,  in  bronchocele,  much  enlarged  and  easily  tied,  226 
Thyroid  gland,  anatomy  of  the,  .....  212 

anomaly  of,  ....  213 

case  of  medullary'  sarcoma  of,  248 

chronic  inflammation  of,  ...  217 

description  of  extirpation  of,  ...  252 

dropsy  of,  . . . ; 217 

extensive  suppuration  of,  case,  . . . 215 


nature  and  severity  of  symptoms  induced  by  its  en- 
largement, determined  bv  the  part  of  gland  affected, 
and  state  of  fascia  aud  muscles  covering  the  tumour,  214 


situation  of,  in  adult,  ....  21S 

Tic  douloureux,  operation  for,  often  fails  because  improperly  per- 
formed, .......  34 

Tongue,  diseased,  may  it  not  be  removed  by  the  knife,  after  securing 

the  lingual  arteries,  ....  - 263 

Tonsil,  inflammation  and  suppuration  of  the,  . . . 279 

extirpation  of,  .....  284 


by  ligature,  ..... 

relations  of  the  ...... 

Tracheotomy,  in  childhood,  preferable  to  laryngotomy, 

carotid  artery  sometimes  endangered  in  this  operation, 
Trachea  to  be  cleared  with  the  fingers,  and  rings  to  be  cut  from  be- 
low upwards,  ...  ... 

Tumours,  anterior  to  the  parotid  duct,  how  to  be  extirpated, 
behind,  ..... 

cervical,  division  into  superficial  and  deep-seated, 

importance  of  this  division  considered  in  a 
practical  point  of  view, 

advantages  of  their  early'  extirpation  illustrated, 
mode  of  extirpating  them, 

connected  with  the  parotid  duct,  .... 
glandular,  above  the  clavicle,  mistaken  for  aneurism, 

over  an  artery  often  pulsate  strongly — causes  why 
they  do  this,  .... 


285 

265 

414 

415 

416 
326 
329 

42 


42 

121 

46 

319 

79 


112 


512 


INDEX. 


Tumours  formed  between  masseter  and  buccinator  muscles,  how  to 

be  discovered,  ...  . . . 323 

from  swelling  of  glandulse  concatenated,  effects  produced  by,  114 
form  over  tht  lachrjmal  sac,  and  are  mistaken  for  com- 
mencement of  fistula  lachrymalis,  . . . S65 

Mr  John  Bell’s  theory  on  their  origin  and  formation,  50 

absurdity  of  this  doctrine  illustrated,  bv  the  formation  and 
progress  of  cancer  and  other  analogous  affections,  . 50 

remarks  on,  in  space  between  the  sterno-mastoid  and  tra- 
pezius muscles,  . . . . , .78 

sacculated  about  the  eye-lids,  treatment  of,  . . 366 

situated  in  antrum  maxillare,  remarks  on,  . 477 

situated  in  antrum  maxillare,  prooi  that  they  will  die,  if 
carotid  artery  of  the  same  side  be  tied,  . . . 4S0 

Undebwood,  James,  his  case  of  tumour  situated  in  antrum  maxillare,  478 
cured  by  tying  the  carotid  artery,  . . 483 

Vica.  D’Aztii,  the  first  proposer  of  laryngotomy,  . . 414 

Vein,  fascial,  course  and  relai ions  of,  ....  352 

Vertebral  artery , anomaly  of,  .....  197 

Wabdrop,  Mr.  his  case  of  fungus  hsematodes  of  the  eye,  . . 368 

Walk,  Agnes — case  where  a calculus  formed  in  the  tonsil,  . 287 

Wilmer  advises  that  the  thyroid  gland  should  not  be  extirpated,  256 

Wishart,  Mr.  his  case  of  gangrene,  subsequent  to  the  operation  for 

aneurism,  . . . . , .178 

cause  assigned  for  its  occurrence,  erroneous,  . 179 


Woman,  case  of,  in  whom  a plum  stone  had  slipped  into  the  trachea,  413 


PLATES 


Description. 

Plate  I. — Anterior  view  of  aneurism  of  arteria  iano- 

minata, . . . . page  71 


Plate  II.— Posterior  view  of  same  preparation,  . . 

Plate  III. — Plan  of  aortic  aneurism,  ...... 

Plate  IV.  Fig.  1st. — External  view  of  tumour  in 
angular  space  above  the  cla- 
vicle,   

2d. — View  of  the  connexions  of  the 
subclavian  artery,  . . . 

Plate  V.  Fig.  1st. — External  view  of  tumour  between 
hyoid  bone  and  thyroid  car- 


74 


To  be  placed. 

page  71 
74 
74 


77 


86 


} 


77 


ti'age, 

119  > 

120 

2d. — Internal  view  of  same  tumour,  . 

120  3 

Plate  VI. — View  of  distribution  of  portia  dura,  . . 

309 

309 

Plate  VII.  Fig.  1st. — Plan  of  a tumour  lying  over  the 

parotid  duct,  .... 

321  1 

2d. — Plan  of  a tumour  lying  behind 

[ 

322 

the  parotid  duct,  .... 

322  J 

Plate  VIII.  Fig.  1st. — External  view  of  anastomosing 

aneurism  around  the  orbit, 

333 

2d. — External  view  of  a tumour  f 

formed  by  a diseased  lach- 

333 

rymal  gland, 

389  ) 

Plate  IX. — View  of  the  openings  of  the  nasal  duct, 

and  sinuses  into  the  nose,  .... 

358 

358 

Plate  X. — View  of  the  relations  of  the  rima  glottidis. 

408 

40S 

65 


I 

Burns